Woburn Home

Profile & contact details

Premises details
Premises nameWoburn Home
Address 57 Wai-iti Crescent Woburn Lower Hutt 5010
Websitewww.psc.org.nz/enliven/rest-homes/woburn-home-lower-hutt/
Total beds110
Service typesRest home care, Geriatric, Medical, Dementia care
Certification/licence details
Certification/licence namePresbyterian Support Central - Woburn Elderly Care
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence13 December 2018
Certification period36 months
Provider details
Provider namePresbyterian Support Central
Street address 3-5 George Street Thorndon Wellington 6011
Post addressPO Box 12706 Thorndon Wellington 6144
Websitewww.psc.org.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: 20 April 2017

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
New service providers receive an orientation/induction programme that covers the essential components of the service provided.Five of 11 staff files had no records of completed orientations. Ensure orientation packs are completed and records are kept on staff file. PA LowReporting Complete11/02/2016
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).(i) There is no current H&S programme being implemented or team responsible for its implementation and review; (ii) the hazard register has not been reviewed or updated since 2012; (iii) a workplace safety inspection checklist completed July 2015 included a list of hazards. There was no documented follow up or mitigation of these identified hazards. (i) Re-establish and implement the H&S programme at Woburn; (ii) Ensure the hazard register is reviewed; (iii) Ensure new hazards are managed appropriately to mitigate the risk PA ModerateReporting Complete11/02/2016
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.While it is noted that the current management team have established the quality system further, following lapses noted in 2014, the following were identified gaps. (i) Meeting minutes have not been completed as per schedule; (ii) meeting minutes do not reflect how quality data is shared with staff; (iii) corrective actions identified through internal audits are not signed out as completed or evaluated; (iv) there have been no resident meetings in 2015. Further establish the quality system by ensuring; (i) meetings are held as per schedule, (ii) quality data and analysis is shared with staff and this is clearly documented; (iii) corrective actions are signed out and evaluated for effectiveness; and (v) implement regular resident meetings. PA LowReporting Complete11/02/2016
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.ARC D17.8; there is a lack of documented records to demonstrate that staff have attended eight hours of staff development in 2015. Ensure staff have completed at least eight hours of training annually and processes are in place to monitor this better. PA ModerateReporting Complete11/02/2016
Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome.Two of the resident files sampled (one rest home, one hospital) do not have up to date InterRAI evaluations. InterRAI evaluations to be evaluated at least six monthly (or earlier as required). PA LowReporting Complete21/03/2016
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.Where the incidence of falls and infection rates (UTIs, respiratory, wounds) were above the benchmark, corrective actions were not consistently documented or implemented. Incidence rates are provided to staff in report and graph form. Where opportunities are identified for improvements, ensure that corrective actions are documented and implemented. PA LowIn Progress
Where progress is different from expected, the service responds by initiating changes to the service delivery plan.i) In three of six files sampled (two rest home and one dementia), the long-term care plan was not updated following a change in health condition, specifically: a) discontinuation of narcotic analgesia; b) a change in mobility; and c) an increase to two-person assistance for showering. ii) Three of six residents (two rest home and one hospital) did not have the short-term care plans evaluated and the interventions added to the long-term care plan for the management of wounds, infections and pain… (this text has been trimmed due to space limits).i) Ensure the long-term care plan is updated following a change in care needs. ii) Ensure that short-term care plans are evaluated and signed out and where required, the long-term care plan is updated. iii) Ensure that the long-term care plan is updated following a change in care level. PA LowIn Progress
Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.Two of two residents on Warfarin had the variable daily dose individually charted and then bracketed and group signed by the GP. Ensure that all medication is prescribed according to guidelines and legislative requirements. PA LowIn Progress
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.(i) In six of six (two rest home, two dementia and two hospital- including one respite) resident files sampled, interventions were not documented or not documented in sufficient detail to support care for: a) one hospital resident (hospital tracer) did not have interventions documented in sufficient detail for the management of a high falls and high pressure injury risk; b) one hospital resident with type II diabetes on insulin with fluctuating blood sugars, had no emergency diabetic management… (this text has been trimmed due to space limits).i) Ensure that interventions are documented for all assessed care needs, in sufficient detail to guide the care staff and that all interventions in use are documented. ii) Ensure that all required monitoring is completed and documented. iii) Ensure that neurological observations are completed for all unwitnessed falls as required by the organisational policies. PA ModerateIn Progress
Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.Two of two resident files sampled in the dementia unit did not have a 24-hour recreational plan documented. Ensure that all residents in the dementia unit have a 24-hour recreational plan documented. PA LowIn Progress

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: 20 April 2017

Audit type:Surveillance Audit

Audit date: 07 October 2015

Audit type:Certification Audit

Audit date: 11 August 2014

Audit type:Surveillance Audit

Audit date: 11 October 2012

Audit type:Certification Audit

Audit date: 12 December 2011

Audit type:Surveillance Audit

Audit date: 04 October 2010

Audit type:Certification Audit

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