Premise details
- Address
- 81 Stone Street Wanaka 9305
- Website
- https://psotago.org.nz/services/residential-aged-care/elmslie-house/
- Total beds
- 31
- Service types
- Geriatric, Medical, Rest home care
Certification/licence details
- Certification/licence name
- The Ultimate Care Group Limited - Alden Elmslie House
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 12 months
Provider details
- Provider name
- The Ultimate Care Group Limited
- Street address
- Level 2 111 Johnsonville Road Johnsonville Wellington 6037
- Postal address
- PO Box 425 Waterloo Quay Wellington 6140
- Website
- http://www.ultimatecare.co.nz/
Progress on issues from the last audit
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.
| Outcome required | Found at audit | Action required | Risk rating | Action status | Date action reported complete |
|---|---|---|---|---|---|
| Fundamental to the development of a care or support plan shall be that: (a) Informed choice is an underpinning principle; (b) A suitably qualified, skilled, and experienced health care or support worker undertakes the development of the care or support plan; (c) Comprehensive assessment includes consideration of people’s lived experience; (d) Cultural needs, values, and beliefs are considered; (e) Cultural assessments are completed by culturally competent workers and are accessible in all settin | (i).Two rest home residents on anticoagulants did not have risks identified in the care plan. (ii). One rest home resident recently admitted did not have sufficient interventions documented to manage assessed needs related to falls risk, undernutrition and management of moods. (iii). One resident who identified as Māori had minimal interventions documented around cultural needs, or assessed needs of falls prevention, equipment in use and behaviour management. | (i). – (iii). Ensure all care plan interventions are current, individualised and reflect the assessed needs of residents. | PA Low | Reporting Complete | |
| 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 | (i). Neurological observations were not completed as per policy for four of six monitoring carts reviewed. (ii). RN progress notes were not documented as per policy for two of five resident files reviewed. (iii). Two wounds plans document two individual wounds on the same plan. | (i). Ensure all neurological observations are completed as per policy. (ii). Ensure progress notes evidence weekly (at least) RN review. (iii). Ensure each individual wounds are documented on an individual plan. | PA Low | Reporting Complete | |
| A medication management system shall be implemented appropriate to the scope of the service. | (i). Weekly medication checks of controlled drugs are not consistently completed. (ii) The six-monthly controlled drug stocktake has not been completed since 2023. | (i). & (ii). Ensure controlled drug checks are completed as per policy and legislation. | PA Moderate | Reporting Complete | |
| The following aspects of the system shall be performed and communicated to people by registered health professionals operating within their role and scope of practice: prescribing, dispensing, reconciliation, and review. | Four-weekly blister packs and medication changes are not consistently checked in by a RN as per policy. | Ensure medications are checked in by an RN as per policy. | PA Moderate | Reporting Complete | |
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | Eight of ten internal audits where corrective actions were identified, did not evidence completion and sign off. | Ensure all required corrective actions are completed as signed off. | PA Low | Reporting Complete | |
| Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services. | Registered nurses have not yet been employed for providing hospital level of care to meet the ARRC contract. | Ensure there is sufficient registered nurses coverage to meet the requirements of the ARRC contract clause D17.4 a (i). | PA Low | Reporting Complete | |
| Service providers shall engage with people receiving services to assess and develop their individual care or support plan in a timely manner. Whānau shall be involved when the person receiving services requests this. | (i). One resident did not have initial assessments or an initial care plan for three months. (ii). Initial interRAI assessments were not documented within 21 days for three of four files reviewed. (iii). Care plans were not documented within 21 days for two of four files reviewed. (iv). InterRAI reassessments were not documented six-monthly for two of three resident files where required. (v). One of two care plan evaluations were not completed within required timeframes. (vi). InterRAI assessme | (i). – (v). Ensure initial assessments, initial care plans, interRAI assessments, long-term care plans and care plan reviews are documented within required timeframes. (vi). Ensure interRAI assessments occur prior to care planning and care plan evaluations. (vii). Ensure short-term care plans are reviewed regularly and either closed or transferred to the long-term care plan in a timely manner. (viii). Ensure the GP completes an initial visit within five days of admission. | PA Moderate | Reporting Complete | |
| The physical environment, internal and external, shall be safe and accessible, minimise risk of harm, and promote safe mobility and independence. | Hot water temperatures checks were reviewed for 2025 year to date. There was no documented evidence of corrective actions being completed for twelve temperatures above the required threshold (45 degrees Celsius). | Ensure that corrective actions are completed for any hot water temperatures above the required threshold (45 degrees Celsius). | PA Low | Reporting Complete |
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 corrective action manager.
- Date action reported complete
The date that the corrective action manager was told the issue was fixed.
Audit reports
About audit reports
Audit reports for this rest home’s latest audits can be downloaded below.
Before you begin
Before you download the audit reports, please read our guide to rest home certification and audits. The guide gives an overview of the auditing process and explains what the audit reports mean.
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.
Before 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) appear on the rest home’s page. As the rest home completes the required actions, the status on the website updates.
Audit date:
Audit type: Provisional Audit
