Thornton Park Retirement Lodge

Profile & contact details

Premises details
Premises nameThornton Park Retirement Lodge
Address 137 State Highway 35 RD 1 Opotiki 3197
Total beds42
Service typesRest home care, Geriatric, Medical
Certification/licence details
Certification/licence nameThornton Park Retirement Lodge Limited - Thornton Park Retirement Lodge
Current auditorHealthShare Limited
End date of current certificate/licence11 January 2019
Certification period24 months
Provider details
Provider nameThornton Park Retirement Lodge Limited
Street address 137 State Highway 35 RD 1 Opotiki 3197
Post addressPO Box 550 Opotiki 3162

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: 21 November 2016

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.There is not always documentation of resolution of issues particularly when issues are identified at meetings. Ensure that there is resolution of issues in a timely manner. PA LowIn Progress
Where progress is different from expected, the service responds by initiating changes to the service delivery plan.Short term care plans are not consistently completed for short term problems. Provide evidence short term care plans are completed for short term problems. PA ModerateIn Progress
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Staff have not had sufficient training over the past two years to include clinically based topics and changes to policy and procedure. Review and implement the annual training plan to include clinically based topics and changes to policy and procedure. PA LowIn Progress
Advance directives that are made available to service providers are acted on where valid.In one of eight advanced directives, the person who had enduring power of attorney had signed the advanced directive, and in the other three advanced directives reviewed, an old form was used that did not clearly document the competency of the resident. Ensure all advance directives where the resident is deemed competent are signed by the resident. PA LowIn Progress
All records pertaining to individual consumer service delivery are integrated.Resident records are not integrated. Ensure that relevant information is kept in an individual file. PA LowIn Progress
The service develops and implements policies and procedures that are aligned with current good practice and service delivery, meet the requirements of legislation, and are reviewed at regular intervals as defined by policy.Policies and procedures do not link to legislation and do not reflect changes in practice. Review policies to reflect links to legislation and changes in practice PA LowIn Progress
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.Not all incidents that are unwitnessed or that include an injury to the head show that neurological recordings are taken for a sustained period. Incident forms are not always documented as part of the adverse event reporting process. Monitor the condition of any resident who has an unwitnessed fall or where there are injuries to the head for a sustained period. Ensure that all incidents and accidents are documented by staff according to policy. PA ModerateIn Progress
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.Meetings are not fully documented to include evidence of clinical discussion, practice and to show discussion of all aspects of quality and risk management. Risk assessments are not always carried out six monthly as per schedule. An internal audit of resident files is not completed. Ensure that discussion of clinical aspects of care, practice and discussion of quality data and risk management information occurs and is documented. Continue to implement the six-monthly schedule of risk assessments. Develop and implement an internal audit of resident files. PA ModerateIn Progress
All buildings, plant, and equipment comply with legislation.The last calibration of medical equipment occurred over a year ago. Ensure that medical equipment is calibrated annually. PA LowReporting Complete04/04/2017
The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.Reporting to external authorities has not been completed as per contractual specifications. Ensure that any requirements to report to external authorities are met. PA ModerateReporting Complete19/06/2017
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.GP initial assessments are not consistently completed within the required timeframes. Provide evidence the GP initial assessments are completed within the required timeframes. PA ModerateReporting Complete29/11/2017
The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.The organisational plans are not detailed sufficiently to include actions, accountabilities and timeframes with evidence of review at regular intervals. Complete documentation of current plans and review at regular intervals throughout the year. PA LowReporting Complete29/11/2017
All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.Not all aspects of food service comply with current legislation and guidelines, such as: dating of decanted foods; monitoring of food temperatures; cleaning schedule staff sign off; and maintenance of pantry shelves. Provide evidence all aspects of food service comply with current legislation and guidelines. PA LowReporting Complete29/11/2017
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.Not all aspects of the medication management system comply with legislation, protocols and guidelines, such as: six monthly stocktakes of controlled drugs; residents’ photos not dated; dating of discontinued medications not recorded; three monthly medication reviews; and as required medication do not consistently record indication of use. Provide evidence the medication management system complies with legislation, protocols and guidelines. PA ModerateReporting Complete29/11/2017
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.The initial and ongoing risk assessments are inconsistently completed, including interRAI. Provide evidence that initial and ongoing risk assessments are completed PA ModerateReporting Complete29/11/2017
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.The interventions required to address residents’ needs are inconsistently documented on care plans and wound care plans. Provide evidence the care plan interventions are consistent in meeting residents’ assessed needs. PA ModerateReporting Complete29/11/2017

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: 21 November 2016

Audit type:Certification Audit

Audit date: 28 April 2015

Audit type:Surveillance Audit

Audit date: 13 November 2012

Audit type:Certification Audit

Audit date: 19 November 2012

Audit type:Surveillance Audit

Audit date: 10 November 2011

Audit type:Certification Audit

Audit date: 05 May 2011

Audit type:Surveillance Audit

Audit date: 08 November 2010

Audit type:Certification Audit

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