Premise details
- Address
- 25 Adderley Terrace Kaiapoi 7630
- Total beds
- 62
- Service types
- Dementia care, Rest home care, Geriatric
Certification/licence details
- Certification/licence name
- Elsdon Enterprises Limited - Annaliese Haven Rest Home
- Current auditor
- The DAA Group Limited
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- Elsdon Enterprises Limited
- Street address
- 1 Taaffes Glen Road Rangiora 7472
- Postal address
- 1 Taafes Glen Road RD 2 Rangiora 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 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. | Thirteen out of 19 staff working in the dementia care unit are not yet enrolled in the NZQA programme. | Ensure all HCAs working in the dementia wing complete the required training within the required timeframe. | PA Low | Reporting Complete | |
| Service providers shall develop and implement policies and procedures in accordance with good employment practice and meet the requirements of legislation. | The HR processes have not been followed for the volunteers working with the activities team. | Ensure the HR processes are followed for the volunteers working with the activities team. | PA Low | Reporting Complete | |
| Information held about health care and support workers shall be accurate, relevant, secure, and confidential. Ethnicity data shall be collected, recorded, and used in accordance with Health Information Standards Organisation (HISO) requirements. | Ethnicity data for staff was not being collected, recorded and used in line with the Health Information Standards Organisation. | Ensure ethnicity data for staff is being collected, recorded and used in line with the Health Information Standards Organisation. | PA Low | Reporting Complete | |
| Service providers demonstrate routine analysis to show entry and decline rates. This must include specific data for entry and decline rates for Māori. | There was no process in place to analyse entry and decline data and this had not occurred. | Ensure there is routine analysis of entry and decline data, including for Māori. | PA Low | Reporting 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 | Resident’s individual and personal strengths, goals and aspirations were not documented in care plans reviewed. | Ensure the personal strengths, goals and aspirations of residents are documented, and supports to achieve these personal goals are identified. | PA Moderate | Reporting Complete | |
| IP personnel and committees shall participate in partnership with Māori for the protection of culturally safe practice in IP, and thus acknowledge the spirit of Te Tiriti. | The facility was not working in partnership with Māori to ensure culturally safe infection prevention practices. | Ensure infection prevention personnel work in partnership with Māori to provide culturally safe infection prevention practice. | PA Low | Reporting Complete | |
| Meaningful activities shall be planned and facilitated to develop and enhance people’s strengths, skills, resources, and interests, and shall be responsive to their identity. | Diversional therapy planning was generic and did not include individualised activity or diversional therapy goals and did not identify the supports required to meet the residents' individual needs. Four of four care plans reviewed in the dementia unit did not have a description of activities to meet the residents’ individual needs in relation to diversional therapy during the 24-hour period, and did not reflect the residents’ former routines, as required by the provider’s contract with Health Ne | Ensure diversional therapy plans include individual goals and document the supports required to meet those goals. Ensure that all residents in the dementia unit have a description of activities to meet the residents’ individual needs in relation to diversional therapy during the 24-hour period and reflect the residents’ former routines. | PA Moderate | Reporting Complete | |
| Planned review of a person’s care or support plan shall: (a) Be undertaken at defined intervals in collaboration with the person and whānau, together with wider service providers; (b) Include the use of a range of outcome measurements; (c) Record the degree of achievement against the person’s agreed goals and aspiration as well as whānau goals and aspirations; (d) Identify changes to the person’s care or support plan, which are agreed collaboratively through the ongoing re-assessment and review | Care plans had not always been updated following the interRAI assessment or when a residents’ needs changed and did not include all identified needs of the residents. Not all triggered clinical assessment protocols were included in care plans. Not all behavioural support care planning for residents in the secure dementia unit included identified triggers, and did not include personalised prevention-based strategies for minimising or de-escalating episodes of challenging behaviour. Plans did n | Ensure care plans are updated after the interRAI assessment and/or when a resident’s needs change, and that interventions are planned to meet all identified needs of the residents including all clinical assessment protocols triggered in the interRAI assessment. Ensure that all residents in the secure dementia unit have a behaviour support plan that identifies their individual triggers and appropriate de-escalation strategies for each resident, and that the plan shows how the behaviour of the in | PA Moderate | Reporting Complete | |
| The nutritional value of menus shall be reviewed by appropriately qualified personnel such as dietitians. | The menu had not been reviewed by a dietitian to confirm the nutritional value. | Ensure the menu is reviewed by a qualified dietitian to confirm the nutritional value meets the needs of residents. | PA Low | Reporting Complete | |
| There shall be evidence of audit and corrective actions, if applicable, of the appropriate decontamination of reusable medical devices based on recommendations from the manufacturer and best practice standards. | There was no audit of the decontamination of shared equipment and medical instruments used for wound dressings and podiatry. Staff were unable to confirm appropriate levels of decontamination had occurred. | Ensure there is audit and corrective action, if applicable, of the appropriate decontamination of reusable medical instruments and shared equipment. | 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: Certification Audit
Audit date:
Audit type: Surveillance Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Partial Provisional Audit
