Torbay Rest Home
Profile & contact details
|Premises name||Torbay Rest Home|
|Address||102 Glenvar Road Torbay Auckland 0630|
|Service types||Rest home care|
|Certification/licence name||Torbay Rest Home Limited|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||16 January 2018|
|Certification period||24 months|
|Provider name||Torbay Rest Home Limited|
|Street address||102 Glenvar Road Torbay Auckland 0630|
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: 02 December 2016
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|The organisation has a clearly defined and documented infection control programme that is reviewed at least annually.||The infection control programme had not been reviewed in past 12 months.||Ensure that the infection control programme is formally reviewed at least annually.||PA Low||Reporting Complete||18/04/2016|
|All buildings, plant, and equipment comply with legislation.||Hot water temperature checks have not been completed for six months.||Undertake regular monitoring of hot water temperatures in resident areas to ensure that hot water temperatures meet all compliance requirements.||PA Low||Reporting Complete||18/04/2016|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i) One of two wounds (BCC lesion) had no wound care plan documented. (ii) Two of two wounds did not have documented wound evaluations with each dressing change.||Ensure wound management plans are documented and wound progress is evaluated.||PA Low||Reporting Complete||18/04/2016|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||(i) Five of seven files reviewed did not have care plans documented for acute changes in health condition (chest infection, wounds and challenging behaviour); four of seven long term care plans did not have all identified interventions documented to manage current needs.||Ensure that care plans are documented for all identified care needs.||PA Low||Reporting Complete||18/04/2016|
|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.||In four of seven files reviewed nursing assessment tools were not used for acute changes in health condition for; a) two residents with chronic and acute pain, b) one resident who stated they felt depressed, and c) one resident with challenging behaviour.||Ensure that assessments are documented for acute changes in health condition.||PA Low||Reporting Complete||18/04/2016|
|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.||Two of seven files reviewed showed that the residents were not seen by the GP within 48 hours of admission. One resident had the initial assessment documented by the GP 27 days after admission and the second resident’s initial GP assessment was documented eight days after admission.||Ensure that all initial GP assessments are completed within the required timeframes.||PA Low||Reporting Complete||18/04/2016|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||Food temperate checks are not consistently completed prior to the food being served to the residents.||Ensure that food served to residents is at a temperature that meets current legislation and guidelines.||PA Low||Reporting Complete||18/04/2016|
|Consumers who have additional or modified nutritional requirements or special diets have these needs met.||The cook was unaware of the special dietary requirements for: i) One resident with celiac disease, ii) One resident noted to have an allergy to peanuts.||Ensure that information about special dietary requirements and food allergies is communicated and understood by all kitchen staff.||PA Low||Reporting Complete||18/04/2016|
|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) One of 14 medication charts reviewed had multiple medications bracketed with a single GP signature. ii) On two separate occasions on the days of audit, the medication trolley was found unlocked in an open office area.||i) Ensure that GP prescribing of medication meets legislative requirements. ii) Ensure that medication is stored safety and medication storage meets all legislation and guidelines.||PA Low||Reporting Complete||18/04/2016|
|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.||Seven of ten accident/incident forms reviewed were not completed in full. The registered nurse is expected to investigate each event and document an ‘outcome summary’ and ‘required actions’ following each event and document this on the form.||Ensure the accident/incident form is completed in its entirety. Areas deemed ‘not applicable’ should be documented as such.||PA Low||Reporting Complete||18/04/2016|
|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).||Hazards identified during the audit included an uneven surface outdoors (noting this was council land); and windows and doors were left open in the kitchen on the first day of the audit, attracting flies. These hazards were included on the register during audit and actions implemented to mitigate risk.||Ensure hazards are documented on a hazard identification form with evidence of each hazard being addressed/mitigated.||PA Low||Reporting Complete||18/04/2016|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||There is a lack of documented evidence to verify that corrective action plans are implemented and signed off.||Ensure there is evidence to verify corrective action plans are implemented and signed off.||PA Low||Reporting Complete||18/04/2016|
|Consumers have a right to full and frank information and open disclosure from service providers.||Six of ten incident/accident forms reviewed did not reflect families being informed.||Ensure families are kept informed following accidents/incidents.||PA Low||Reporting Complete||18/04/2016|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||An RN is on-site five days a week and is reported to be on call when not available on-site. The nurse manager reported that the name of the RN on call is identified in the staff communication book. It was noted by the auditor that the RN on call is not consistently documented in the staff communication book or on the staff roster. This was addressed on the day of audit.||Ensure that the RN on call is clearly identified in writing.||PA Low||In Progress|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||(i)Caregivers reheat and serve the evening meal but do not check or record food temperatures. (ii)Hats are not worn during food preparation.||(i)Ensure food temperatures are checked and recorded before the evening meal is served. (ii)Ensure hats are worn during food preparation.||PA Low||Reporting Complete||14/06/2017|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||There was no documented evidence to confirm that corrective actions had been implemented at the time of writing and signed off to address identified recommendations.||Ensure that corrective actions are documented as regularly evaluated and signed off when completed.||PA Low||Reporting Complete||14/06/2017|
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: 02 December 2016
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit