Windsor Park Specialist Senior Care Centre

Profile & contact details

Premises details
Premises name	Windsor Park Specialist Senior Care Centre
Address	3 McKellar Street Gore 9710
Total beds	79
Service types	Physical, Dementia care, Rest home care, Geriatric, Medical

Certification/licence details
Certification/licence name	Bupa Care Services NZ Limited - Windsor Park Specialist Senior Care Centre
Current auditor	Health and Disability Auditing New Zealand Limited
End date of current certificate/licence	30 October 2024
Certification period	36 months

Provider details
Provider name	Bupa Care Services NZ Limited
Street address	Level 2 109 Carlton Grove Road Newmarket Auckland 1023
Post address	PO Box 113054 Newmarket Auckland 1149
Website	www.bupa.co.nz/

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: 16 March 2023

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.	Eight (two hospital, two rest home and four dementia) of fourteen electronic incident reports reviewed did not document opportunities to minimise future risks.	Ensure opportunities to minimise future risks are identified and documented on incident reports and included in care plan interventions.	PA Low	Reporting Complete	22/03/2022
The service is able to demonstrate that written consent is obtained where required.	Two of three resident files reviewed from the dementia unit did not have consents updated when the change in level of care was increased to dementia level care.	Ensure all resident consents are updated when the residents have a change in their level of care.	PA Low	Reporting Complete	24/05/2022
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.	There was no documented evidence of discussions with staff around quality data, including benchmarking results and corrective actions.	Ensure meeting minutes include discussions with staff around quality data results.	PA Moderate	Reporting Complete	24/08/2022
A process to measure achievement against the quality and risk management plan is implemented.	Internal audits for building compliance, emergency procedures, code of rights knowledge, cleaning, kitchen and nursing audits, first impressions, and an environmental offices audit were not completed in 2020.	Ensure internal audits are held as scheduled and results are discussed at meetings.	PA Low	Reporting Complete	24/08/2022
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.	There were no corrective actions identified for internal audits with less than 95% compliance including clinical files, care planning, multi-disciplinary reviews, restraint, manual handling, admissions, office spaces, first impressions and food services.	Ensure all corrective actions are identified, followed up and progression towards completion is recorded for ongoing issues, and all corrective actions are signed off and discussed at meetings.	PA Low	Reporting Complete	24/08/2022
Buildings, plant, and equipment shall be fit for purpose, and comply with legislation relevant to the health and disability service being provided. The environment is inclusive of peoples’ cultures and supports cultural practices.	Hot water temperatures have been consistently between 46 and 48 in several resident areas for 2023.	Ensure hot water temperatures are maintained at 45 degrees or below.	PA Low	In Progress
Service providers shall evaluate progress against quality outcomes.	(i).The schedule of 2022 audits were not completed as per schedule. (ii). Quality data is not discussed at meetings. (iii). The hazard/risk register has not been reviewed since 2021	(i). Ensure audits are completed according to the documented schedule. (ii). Ensure quality data is discussed at relevant meetings. (iii). Ensure the hazard register is reviewed and updated	PA Moderate	In Progress
In implementing care or support plans, service providers shall demonstrate: (a) Active involvement with the person receiving services and whānau; (b) That the provision of service is consistent with, and contributes to, meeting the person’s assessed needs, goals, and aspirations. Whānau require assessment for support needs as well. This supports whānau ora and pae ora, and builds resilience, self-management, and self-advocacy among the collective; (c) That the person receives services that remov… (this text has been trimmed due to space limits).	Neurological observations for three of four unwitnessed falls were not completed according to policy.	Ensure all neurological observations are completed as per policy.	PA Low	In Progress
Service providers shall ensure health care and support workers are able to provide a level of first aid and emergency treatment appropriate for the degree of risk associated with the provision of the service.	There are shifts where there are no members of staff with a current first aid certificate.	Ensure there is a member of staff with a current first aid certificate on duty at all times.	PA Low	In Progress
A medication management system shall be implemented appropriate to the scope of the service.	(i). Two eyedrops in the medication trolley in current use, were past the manufacturer’s guidelines. (ii). One eyedrop and one crème in use did not evidence an opening date.	(i)-(ii). Ensure all eyedrops are dated with opening dates and all date sensitive medications are discarded as per manufacturer’s instructions.	PA Moderate	Reporting Complete	23/11/2023

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.

From 1 June 2009 to 28 February 2022 rest homes were audited against the Health and Disability Services Standards NZS 8134:2008. These standards have been updated, and from 28 February 2022 rest homes are audited against Ngā Paerewa Health and Disability Services Standard NZS 8134:2021.

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 Ngā Paerewa Health and Disability Services Standard.

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: 16 March 2023

Audit type:Surveillance Audit

Audit date: 11 August 2021

Audit type:Certification Audit

Audit date: 13 November 2019

Audit type:Surveillance Audit

Audit date: 21 August 2017

Audit type:Certification Audit

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