Terence Kennedy House
Profile & contact details
|Premises name||Terence Kennedy House|
|Address||267 Glengarry Road Glen Eden Auckland 0602|
|Service types||Medical, Rest home care, Geriatric|
|Certification/licence name||Residential Management Limited|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||01 July 2017|
|Certification period||36 months|
|Provider name||Residential Management Limited|
|Street address||267 Glengarry Road Glen Eden Auckland 0602|
|Post address||PO Box 121003 Henderson Auckland 0650|
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: 08 December 2015
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|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.||Three of the fourteen medication charts (all from the hospital) reviewed did not show evidence of a documented time for PRN medications given||Ensure that all PRN medication given have a documented time.||PA Low||Reporting Complete||13/08/2014|
|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.||D16.2, 3, and 4: Two of the seven files (one from the hospital and one from the rest home) sampled did not show evidence that the initial care plan was completed within 48 hours of admission.||Ensure that all initial care plans for residents are completed within 48 hours of admission.||PA Low||Reporting Complete||13/08/2014|
|Consumers have a right to full and frank information and open disclosure from service providers.||Five of the 13 incident forms reviewed did not indicate family were informed.||Ensure family are informed of all incidents.||PA Low||Reporting Complete||02/09/2014|
|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 one resident with a lap belt is not having this montiored at the fequency stated.||Ensure all restraints are monitored at the identified frequency.||PA Low||Reporting Complete||11/09/2014|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||Seven of seven staff files sampled do not have a current annual performance appraisal.||Ensure all staff have an annual performance appraisal.||PA Low||Reporting Complete||10/11/2014|
|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).||Monitoring of a resident wearing a lap belt was not completed as per the frequency determined on the restraint assessment form.||Ensure that restraint monitoring forms are completed as per the frequency determined on the resident’s restraint assessment form.||PA Moderate||Reporting Complete||26/04/2016|
|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.||An assessment for one resident with enabler use was completed 30 days after the bedrails had been put into place.||Ensure residents undergo an assessment for enabler use prior to using the enabler.||PA Low||Reporting Complete||26/04/2016|
|Service providers responsible for medicine management are competent to perform the function for each stage they manage.||No staff medication competencies have been completed in 2015.||Staff who administer medication are required to have their medication competency checked annually||PA Moderate||Reporting Complete||26/04/2016|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||Staff in-service attendance rates have fallen below 50%.||Ensure staff attend education and training, meeting contractual requirements. Training on restraint minimisation and safe practice is overdue.||PA Low||Reporting Complete||26/04/2016|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Missing is evidence of corrective actions where improvements are required, and sign off of corrective actions when implementation is evidenced.||Ensure corrective actions are developed, implemented and signed off where opportunities for improvements are identified.||PA Low||Reporting Complete||26/04/2016|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||There is a lack of documented evidence to reflect quality and risk data is being collected, analysed and results provided to staff in staff meeting. Note: this finding does not include the infection control surveillance programme or complaints received.||Ensure that quality data is collected, analysed and shared with staff in staff meetings.||PA Low||Reporting Complete||26/04/2016|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Job descriptions were missing in four of five staff files reviewed. Evidence of completed induction programmes were missing in three of five staff files reviewed.||Ensure staff are provided with a copy of their job description and that this can be evidenced in the staff file. Ensure evidence of completed orientation programmes are held in staff files.||PA Low||Reporting Complete||09/05/2016|
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: 08 December 2015
Audit type:Surveillance Audit
Audit type:Certification Audit
- Terence Kennedy House - May 2014 (docx, 131.17 KB)
- Terence Kennedy House - May 2014 (pdf, 802.22 KB)
Audit type:Surveillance Audit
Audit type:Certification Audit