The Willows Home and Hospital

Profile & contact details

Premises details
Premises nameThe Willows Home and Hospital
Address 16 Princes Street Otahuhu Auckland 1062
Total beds29
Service typesRest home care, Geriatric, Medical
Certification/licence details
Certification/licence nameThe Willows Home and Hospital Limited - The Willows Home and Hospital
Current auditorThe DAA Group Limited
End date of current certificate/licence20 March 2020
Certification period36 months
Provider details
Provider nameThe Willows Home and Hospital Limited
Street address16 Princes Street Otahuhu Auckland 1062
Post address16 Princes Street Otahuhu Auckland 1062

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: 07 February 2017

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
All buildings, plant, and equipment comply with legislation.Electrical safety checks are overdue. Not all painted surfaces, including a chipped area in the kitchen benchtop, are of a standard to meet infection control cleaning standards. Provide evidence of up to date electrical appliance checking, and that infection control cleaning standards can be met for all washable surfaces. PA ModerateReporting Complete01/08/2017
Service providers responsible for medicine management are competent to perform the function for each stage they manage.HCAs who check controlled medication have not completed a documented competency check, as required by the organisational policy. Provide evidence that all staff who undertake any stage of medication management have a documented competency. Provide evidence that all staff who check medications are assessed as competent to perform their role. PA LowReporting Complete01/08/2017
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.The controlled drug register does not consistently show that weekly checks are undertaken. Provide evidence that the weekly controlled drug checks are recorded in the controlled drug register. PA ModerateReporting Complete01/08/2017
An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.Complaints that are verbalised and deemed of a minor nature, such as issues around laundry, are not documented in the complaints register. No follow up actions are documented related to this issue. Provide evidence that all complaints are documented and recorded in the complaints register. PA LowReporting Complete01/08/2017
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.Corrective action documentation is not undertaken consistently. Provide evidence that all matters requiring a corrective action are documented. PA LowReporting Complete01/08/2017
The organisation has a clearly defined and documented infection control programme that is reviewed at least annually.The infection control programme has not been reviewed in the past year. Provide evidence that the infection control programme is reviewed at least annually. PA LowReporting Complete25/09/2017

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: 07 February 2017

Audit type:Certification Audit

Back to top