Premise details
- Address
- 17 Fraser Avenue Northcote Auckland 0627
- Website
- https://www.annemareecourt.co.nz
- Total beds
- 57
- Service types
- Medical, Geriatric, Physical, Rest home care
Certification/licence details
- Certification/licence name
- Anne Maree Court Care Limited - Anne Maree Court Rest Home
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 24 months
Provider details
- Provider name
- Anne Maree Court Care Limited
- Street address
- 28 Aston Road RD 1 Waikanae 5391
- Postal address
- 28 Aston Road RD 1 Waikanae 5391
- Website
- https://annemareeresthome.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 |
|---|---|---|---|---|---|
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | (i). Internal audits including medication, cleaning, laundry, maintenance, continence, health and safety, privacy, chemical safety, staff files, culture, wound care and skin, kitchen have not been evidenced as being completed as scheduled. (ii). There is no evidence of follow-up of actions from meetings and sign off when completed. (iii). There is no evidence of collation and analysis of results from residents and staff satisfaction surveys to inform quality improvements. | (i). Ensure internal audits are completed as scheduled. (ii). Ensure corrective actions are followed up and signed off when completed. (iii). Ensure results of satisfaction surveys are collated and analysed. | PA Moderate | In Progress | |
| Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services. | There is no evidence to demonstrate cover or backfill for six unplanned absences during the two week roster reviewed at the time of audit. | Ensure backfill or cover for unplanned absences on the roster | PA Low | In Progress | |
| 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). Two care plans and three interRAI assessments were not completed within 21 days of resident admission. (ii). Three interRAI assessments had not been reviewed within the 6-month timeframe. | (i). & (ii). Ensure care plans and all assessments and reassessments are completed within the required timeframes. | PA Moderate | In Progress | |
| Service providers shall evaluate progress against quality outcomes. | There is no evidence of analysis of incidents, accidents and infections, implementation of quality improvements and evaluation of actions to ensure continuous quality improvement of service delivery. | Ensure there is evidence of analysis of incidents, accidents and infection, implementation of quality improvements and evaluation of actions to ensure continuous quality improvement of service delivery. | PA Moderate | In Progress | |
| Governance bodies shall evidence leadership and commitment to the quality and risk management system. | Monthly facility manager reports to the director are not documented consistently to incorporate all quality and risk issues including infection control and restraint. | Ensure there is consistent incorporation of all quality and risk issues to the director. | 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. | (i). Staff meeting have not been evidenced as occurring as scheduled. (ii). Meeting minutes reviewed do not evidence discussion, and analysis of key risk areas such as restraints, infections, adverse events and internal audits. (iii). Resident meeting minutes have not been completed as scheduled. (iv). There is no evidence to show that issues raised in resident meetings have been actioned and signed off when completed | (i). Ensure that meetings are completed as scheduled. (ii). Ensure there is evidence in the minutes of discussion, and analysis of key risk areas such as restraints, infections, adverse events and internal audits. (iii). Ensure resident meetings are completed as scheduled. (iv). Ensure issues raised in resident meetings are actioned and signed off when completed | PA Moderate | 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. | i). There was no signed job descriptions for the cook and one HCA. ii). There was no job description in place for the infection prevention and control coordinator role. | Ensure that signed job descriptions are on staff files. | PA Low | In Progress | |
| 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 | Three of eight resident care plans did not include appropriate interventions or guidance for staff to manage restraint and conditions including challenging behaviour, diabetes, suprapubic catheter, and autonomic dysreflexia. | Ensure care plans are sufficiently detailed to guide staff in the safe care and management of resident’s needs and medical conditions. | PA Low | In Progress | |
| A medication management system shall be implemented appropriate to the scope of the service. | Eight medication fridge temperatures during August were outside of the acceptable range without their being any documented corrective actions. | Ensure corrective actions are carried out to ensure medication fridge temperatures remain within the safe and acceptable range | PA Moderate | 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 are no records to evidence that training including falls prevention, skin care and wound management, challenging behaviour, abuse and neglect, code of right, Treaty of Waitangi, restraints, infection control, chemical safety, complaints, communication, health and safety has been completed by staff to meet standards and contractual requirements. | Ensure that staff complete the required training and there are documented records to evidence this. | PA Low | In Progress | |
| Service providers shall demonstrate a commitment to ensuring the voice of people with lived experience, Māori and whānau, is evident on the restraint oversight groups. | There is not currently a resident or representative with lived experience on the restraint committee. | Ensure a person with lived experience is evident on the restraint oversight group. | PA Low | 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 | Five out of six fall related incidents did not have neurological observations completed as per policy. | Ensure neurological observations are completed as per policy. | PA Moderate | In Progress | |
| Service providers shall understand and comply with statutory and regulatory obligations in relation to essential notification reporting. | There is no evidence to demonstrate that section 31 reporting for facility manager and clinical manager appointment were completed. | Ensure that statutory and regulatory obligations in relation to essential notification reporting is completed | PA Moderate | In Progress | |
| Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided. | There is no evidence of documented orientation for the cook and the clinical manager. | Ensure that there is documented evidence of orientation for all new staff. | PA Low | In Progress | |
| My complaint shall be addressed and resolved in accordance with the Code of Health and Disability Services Consumers’ Rights. | Interview with residents confirmed that they had raised verbal complaints on two different occasions; however, there was no documented evidence of records of the complaints in the register. | Ensure there are documented records of all complaints raised (verbal or written). | PA Low | In Progress | |
| My service provider shall practise open communication with me. | There is no documented evidence of family/whanau being consistently notified following adverse events. | Ensure that family/whānau are notified following adverse events. | PA Low | In Progress | |
| Surveillance methods, tools, documentation, analysis, and assignment of responsibilities shall be described and documented using standardised surveillance definitions. Surveillance includes ethnicity data. | Infection surveillance does not currently include ethnicity data. | Ensure infection surveillance includes ethnicity data. | PA Low | In Progress | |
| A person-centred debrief shall follow every episode of emergency restraint. Participation in this debrief shall be determined by the person when they feel ready. | An episode of emergency restraint occurred without a person-centred debrief following the event. | The service will ensure a person-centred debrief shall follow every episode of emergency restraint. | 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 district health board.
- Date action reported complete
The date that the district health board 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
