Premise details
- Address
- 1 Hilton Drive Amberley 7410
- Website
- https://www.amberleyresthome.co.nz
- Total beds
- 21
- Service types
- Rest home care
Certification/licence details
- Certification/licence name
- Chandys Group Limited - Amberley Resthome and Retirement Village
- Current auditor
- The DAA Group Limited
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- Chandys Group Limited
- Street address
- 88 Hodgsons Road Loburn 7472
- Postal address
- 88 Hodgsons Road Loburn 7472
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 |
|---|---|---|---|---|---|
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | Not all elements of the quality framework, as described in policy and detailed above, had been fully implemented. | Ensure the quality framework described in policy is fully implemented, and that all quality activities described in policy are completed, including staff and resident surveys. Ensure that corrective action planning and quality improvement planning are documented to address shortfalls identified, and that plans include details of actions taken and evaluation of improvements. Ensure all meetings described in policy occur. Ensure minutes are sufficiently detailed to evidence what has occurred, who | PA Moderate | In Progress | |
| Service providers shall evaluate progress against quality outcomes. | No evidence was available to show that progress towards meeting quality outcomes and key performance indicators had been evaluated. | Ensure that progress against quality outcomes is evaluated, documented and reported. | PA Low | In Progress | |
| Service providers shall identify external and internal risks and opportunities, including potential inequities, and develop a plan to respond to them. | The risk register did not include all elements required and evidence was not available to confirm that the risk register had been reviewed, updated and reported to governance. | Ensure the risk register includes all elements required, that it is reviewed and updated at regular intervals, and that risks identified as high risk are reported to and reviewed by governance. | PA Low | In Progress | |
| Service providers shall ensure the skills and knowledge required of each position are identified and the outcomes, accountability, responsibilities, authority, and functions to be achieved in each position are documented. | The clinical nurse manager role was being performed by a nurse employed as a registered nurse in 2020. Staff files and documents could not evidence that the change of position and increase in responsibilities had been formalised and no job description for the clinical nurse manager role describing the outcomes, accountability, responsibilities, authority and function of the role could be found. | Ensure the clinical nurse manager has an employment contract and position description that reflects the outcomes, accountability, responsibilities, authority, and function of the role. | PA Low | In Progress | |
| Service providers demonstrate routine analysis to show entry and decline rates. This must include specific data for entry and decline rates for Māori. | The service could not demonstrate routine analysis of entry and decline rates, including specific data for Māori. Systems to capture, monitor, and report this information through the quality improvement framework are not currently established. | Develop and implement a system to routinely capture, analyse, and report entry and decline rates, including specific data for Māori, and integrate this into the quality and risk management framework. | PA Low | In Progress | |
| Service providers shall ensure there is a system to identify, plan, facilitate, and record ongoing learning and development for health care and support workers so that they can provide high-quality safe services. | There was no education plan in place detailing how and when education would be delivered. Not all staff education was recorded in the staff member’s file. | Ensure there is an education plan developed describing how and when education will be provided. Ensure that all staff education and training is recorded in the staff member's file. | PA Low | In Progress | |
| There shall be a documented pathway for IP and AMS issues to be reported to the governance body at defined intervals, which includes escalation of significant incidents. | The service was unable to evidence that reporting of IP and AMS issues to governance had occurred. | Ensure that IP and AMS issues are reported to governance, and that this is documented in meeting minutes. | PA Low | In Progress | |
| Executive leaders shall report restraint used at defined intervals and aggregated restraint data, including the type and frequency of restraint, to governance bodies. Data analysis shall support the implementation of an agreed strategy to ensure the health and safety of people and health care and support workers. | There was no evidence of reporting of restraint data to governance. | Ensure restraint data required is reported to the directors/owners six-monthly as required by the standard. | PA Low | In Progress | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | Not all staff had a performance review at three months after appointment and annually thereafter, as described in policy. | Ensure that all staff have an opportunity to discuss and review performance at defined intervals and as described in policy. | PA Low | In Progress | |
| Governance bodies shall ensure service providers’ structure, purpose, values, scope, direction, performance, and goals are clearly identified, monitored, reviewed, and evaluated at defined intervals. | No evidence was available to show that monitoring, review and evaluation of progress had occurred. | Ensure that monitoring, review and evaluation of strategic goals occurs at governance level and that this is documented. | PA Low | In 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 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: Certification Audit
Audit date:
Audit type: Provisional Audit
