Voguehaven Rest Home
Profile & contact details
|Premises name||Voguehaven Rest Home|
|Address||143 Main Road Clive 4102|
|Service types||Rest home care|
|Certification/licence name||Vinada Limited - Voguehaven Rest Home|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||01 April 2019|
|Certification period||36 months|
|Provider name||Vinada Limited|
|Street address||Villa 6 178 Charles Street Westshore Napier 4110|
|Post address||PO Box 78 Clive Hastings 4148|
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: 29 January 2016
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|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.||Five of 12 accident/incident forms were for unwitnessed falls. There was no evidence of RN notification, follow-up or sign off on the accident/incident form as per protocol.||Ensure the RN is notified of all unwitnessed falls and documentation reflects follow up.||PA Moderate||Reporting Complete||09/06/2016|
|The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code.||Complaint action reports have not been completed for the five complaints made in 2015.||Ensure that complaints are documented in the complaint action report.||PA Low||Reporting Complete||20/06/2016|
|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.||Of the five files reviewed, one resident had been admitted since 1 July 2015 and did not have an InterRAI assessment completed. The file sample was extended to include the two other residents admitted since 1 July 2015. Two of three new resident admissions since 1 July 2015 have not had an InterRAI assessment completed.||Ensue all new residents have an InterRAI assessment completed within 21 days of admission.||PA Moderate||Reporting Complete||11/07/2016|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Care plans did not reflect the supports and interventions required to achieve outcomes of assessments for (i) falls prevention strategies for five of five residents identified as high falls risk, (ii) pain management plans for four of five residents who identify pain, and (iii) interventions and management for one resident with known behaviours.||Ensure care plans describe the required supports and interventions identified by the assessment process.||PA Moderate||Reporting Complete||12/07/2016|
|A process to measure achievement against the quality and risk management plan is implemented.||1) The 2015 internal audit schedule has not been followed. 2) Survey results have not been collated and the results have not been communicated to the residents/relatives.||1) Ensure the internal audit schedule is followed. 2) Ensure survey results are followed up and communicated to participants.||PA Low||Reporting Complete||11/08/2016|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||End cooked temperatures on poultry are not taken and recorded as per policy.||Ensure end-cooked food temperatures are taken and recorded as per policy.||PA Low||Reporting Complete||05/09/2016|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||The activity plans are not reviewed at the same time as the care plans as per ARC contract D 16.3 g iii.||Ensure activity plans are reviewed at the same time as the care plan.||PA Low||Reporting Complete||28/11/2016|
|The appointment of appropriate service providers to safely meet the needs of consumers.||Five staff files were reviewed. There was no documented evidence of an employment agreement in one out of five files, job description were missing in three out of five files, orientation checklist were not included in three out of five files and performance appraisals were not evidenced to be completed in two out of five files reviewed.||Ensure that all staff files have a copy of an employment agreement, job description, completed orientation checklist and performance appraisal||PA Moderate||In Progress|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||Not all mandatory training has been completed within the required two year period. The mandatory training not completed during this period was abuse and neglect, nutrition/hydration, pain management, privacy/dignity, end of life/death, the aging process and spirituality/counselling.||Ensure that all mandatory training is provided within the required two year period.||PA Moderate||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.||There was no updated restraint register confirming the one resident using an enabler. The resident using an enabler did not have a signed consent form||Ensure that an up-to-date restraint register is in place. A consent form is completed and signed for the resident using an enabler.||PA Low||In Progress|
|All records are legible and the name and designation of the service provider is identifiable.||In five of five files reviewed staff did not always document time and designation in the progress notes at each entry||Ensure progress note entries are documented with name, designation, time and date clearly recorded||PA Low||In Progress|
|Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is undertaken by suitably qualified and/or experienced service providers who are competent to perform the function.||Four of five resident files sampled did not contain documented evidence of regular assessment/input by the RN. Progress notes had periods ranging from one to two months where no nursing assessments or reviews were documented.||Ensure that RN follow up, (assessments and reviews) are completed and documented regularly in the progress notes.||PA Moderate||In Progress|
|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 five (admitted since October 2016) files did not have interRAI assessment documented within three weeks of admission. (ii) Four of five (been in facility since 1996, 2010, 2015, October 2016) resident files reviewed did not have a current interRAI assessment completed by the RN, one had no interRAI (been in the facility since October 2016). (iii) One LTCP has not been completed with 3 weeks of admission||Ensure that contractual timeframes around resident assessments and care plans are met.||PA Moderate||In Progress|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Care plans did not reflect the supports and interventions required to achieve outcomes of assessments for (i) falls prevention strategies for one of five residents identified with high falls risk, (ii) pain management plan for one of five residents with a wound who identified pain and (iii) one resident file did not document diabetes management in sufficient detail (no instruction re management of hypo/hyperglycaemia for a diabetic on insulin).||Ensure care plans describe the required supports and interventions identified by the assessment process.||PA Moderate||In Progress|
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: 29 January 2016
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Certification Audit
Audit type:Surveillance Audit