Premise details
- Address
- 149 Racecourse Road Glengarry Invercargill 9810
- Total beds
- 104
- Service types
- Dementia care, Rest home care, Geriatric, Medical, Physical
Certification/licence details
- Certification/licence name
- Bupa Care Services NZ Limited - Ascot Care Home
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- Bupa Care Services NZ Limited
- Street address
- Level 2 109 Carlton Grove Road Newmarket Auckland 1023
- Postal address
- PO Box 113054 Newmarket Auckland 1149
- Website
- http://www.bupa.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 |
|---|---|---|---|---|---|
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | Three of the five that were due for a performance appraisal did not have a current appraisal on file. | Ensure all staff complete annual appraisals as scheduled, and a copy is retained on file. | 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. | i). The service has been unable to provide a RN on site on some afternoon and night shifts for hospital level care residents since February 2022 – August 2023. From September – October 2023, there has been no RN on night shift. The service has mitigated the risk of this situation by using the EVS. The service does not have enough RNs to always have an RN on duty as per the ARC contract D17.4 a. i. ii). At interviews with RNs and caregivers, there have been at least three occasions over the past | i). Ensure a RN is always on duty to meet the requirements of the ARC contract D17.4 a. i. ii). Ensure the rostered number of caregivers are on site to meet the staffing policy. iii). Ensure there are staff available to run the activity programme across the service. | PA Moderate | Reporting Complete | |
| Service providers shall ensure their health care and support workers have the skills, attitudes, qualifications, experience, and attributes for the services being delivered. | Six of the permanent caregivers in the dementia unit are enrolled or in progress to complete the dementia specific standards according to the ARRC clause E4.5.f, and the remaining six are enrolled and in progress. These staff are all outside the 18-month timeframe for completion. | Ensure caregivers employed in the dementia unit complete the dementia specific standards according to the ARRC clause E4.5.f within the required timeframes. | PA Low | Reporting Complete | |
| Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided. | Six of the ten staff files reviewed did not evidence completed orientation. | Ensure there is evidence of completed orientation on staff files. | 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. | Two of three residents in the dementia unit did not have an interRAI and long-term care plan completed within the required 21 days. | Ensure all interRAI assessments and long-term care plans are developed within expected timeframes for all residents. | 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 | Post fall assessments were not completed for all documented falls for three residents in the dementia unit, two rest home level residents, and one hospital level resident as required by Bupa post falls management policy. | Ensure ongoing assessments and reassessments are completed where/when required. | 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 | Neurological observations were not always completed within the frequency required for 10 documented unwitnessed falls. | Ensure neurological observations are completed within the required frequency for all unwitnessed falls with or without a head injury. | PA Moderate | 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. | (i). The availability of the activities team is inconsistent to meet the needs of the residents: (a) to offer appropriate activities that is meaningful; (b) provide diversion at appropriate times during the day; (c) to meet the needs of residents that require individual activities and (d). facilitate regular community outings. | (i). Ensure meaningful activities are planned and facilitated to develop and enhance people’s strengths, skills, and interests and shall be responsive to their identity. | PA Moderate | Reporting Complete | |
| Service providers shall facilitate safe self-administration of medication where appropriate. | (i). The medication charts did not reflect which medication is for self-administration. (ii). The electronic medication signing sheet did not reflect which medications were self-administered by the resident. (iii). Assessments were not completed three-monthly. | (i)-(iii) Ensure to follow and implement the Bupa medication policy for residents who self-administer their medications. | PA Low | Reporting Complete | |
| Service providers shall identify external and internal risks and opportunities, including potential inequities, and develop a plan to respond to them. | (i) The hazard and risk register was last reviewed in March 2023. (ii) There have been no health and safety committee meetings completed for 2024 and 2025 year to date. | (i) Ensure that the hazard and risk register is reviewed and up to date. (ii) Ensure that the health and safety committee meetings are completed as per policy requirements. | 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. | There were gaps in the rosters reviewed where shifts were not covered by a full compliment of staff in the hospital (Hollyford and Grebe) and rest home (Tutoko and Waikaia) communities. | Ensure there is adequate staff available in the hospital (Hollyford and Grebe) and rest home (Tutoko and Waikaia) communities with consideration of the number of residents, the acuity of residents, and non-clinical tasks allocated to caregivers. | PA Moderate | Reporting Complete | |
| Service providers shall ensure their health care and support workers have the skills, attitudes, qualifications, experience, and attributes for the services being delivered. | There are ten caregivers work permanently in the dementia communities, five have completed, one is in progress of completing and four have not completed the dementia specific standards and are all outside the 18-month required timeframe period. | Ensure that caregivers employed in the dementia communities complete the dementia specific standards according to the ARRC clause E4.5.f within the required timeframes. | PA Moderate | Reporting Complete | |
| Service providers shall implement systems to determine and develop the competencies of health care and support workers to meet the needs of people equitably. | (i) Training records documented low attendance for care staff for a number of compulsory training requirements, including abuse/neglect; the ageing process; death/dying; end of life care; cultural awareness; Te Tiriti o Waitangi; restraint; nutrition/hydration/safe food handling; chemical safety; sexuality/intimacy and complaints management. (ii) There were gaps in the completion of annual competencies for RNs and caregivers in relation to restraint; correct use of personal protective equipment; | (i) Ensure that care staff attend and complete all compulsory training requirements. (ii) Ensure that all RNs and caregivers complete annual competencies as required. | PA Low | Reporting Complete | |
| Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided. | Four of the six staff files reviewed did not evidence completion of the orientation. | Ensure there is evidence of completed orientation on staff files. | PA Moderate | Reporting Complete | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | Four of the six staff files reviewed did not evidence an up-to-date annual performance appraisal. | Ensure all staff complete annual performance appraisals as scheduled and that a copy is retained on file. | PA Moderate | 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 always completed within the frequency required for six documented unwitnessed falls. ii). Monitoring of restraint does not provide information regarding applied or removed (the associated long term care plan was also not reflective of the restraint monitoring - time for bed and time up in the morning. | i). Ensure neurological observations are completed within the required frequency for all unwitnessed falls with or without a head injury. ii). Ensure monitoring of restraint meets the required work instruction, | 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 | Long term care plan evaluations are not reflective of the care and support provided over the previous six months for two rest home residents and two hospital files reviewed. | Ensure care plan evaluation reflect the residents identified goals | PA Moderate | 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: Surveillance Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Surveillance Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Surveillance Audit
