Premise details
- Address
- 92 Rosebank Road Avondale Auckland 1026
- Total beds
- 72
- Service types
- Geriatric, Medical, Dementia care, Rest home care
Certification/licence details
- Certification/licence name
- Avondale Lifecare Limited - Avondale Lifecare
- Current auditor
- The DAA Group Limited
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- Avondale Lifecare Limited
- Street address
- Level 5 25 Broadway Newmarket Auckland 1023
- Postal address
- PO Box 56114 Dominion Road Auckland 1446
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 receive an orientation and induction programme that covers the essential components of the service provided. | Orientation is not being consistently completed an documented for all staff. | A process is put into place to make sure all staff have orientation completed and documented on commencing employment, in line with the organisation’s policy and procedure requirements. | 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. | Three out of eight residents’ files sampled for review did not have initial interRAI assessments and long-term care plans completed within three weeks of admission. In three out of eight files sampled for review routine six-monthly interRAI reassessments were overdue. The interRAI assessment summary report evidenced that 48 routine six-monthly interRAI reassessments were overdue with an interval of between 31 days to 152 days. | Ensure interRAI assessments are completed in a timely manner as per contractual requirements. | PA Moderate | Reporting Complete | |
| Service providers shall have a clearly defined and documented IP programme that shall be: (a) Developed by those with IP expertise; (b) Approved by the governance body; (c) Linked to the quality improvement programme; and (d) Reviewed and reported on annually. | There was no evidence of annual review of the IP programme. | Ensure that the IP programme is reviewed annually to meet the standard requirement. | PA Low | Reporting Complete | |
| Service providers shall ensure the quality and risk management system has executive commitment and demonstrates participation by the workforce and people using the service. | Participation by residents and staff is not consistently taking place. There have been no satisfaction surveys conducted since before 2020. | Ensure residents and staff can consistently participate in quality management activities to improve services within the organisation. | PA Low | Reporting Complete | |
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | Risk, through adverse event and quality indicator analysis, does not link to a risk system to improve organisational practices. Risks to the organisatin are not identified and mitigated. Most of the policies and procedures are out-of-date and not fit for purpose. | Adverse events and quality indicators need to be analysed and trended for opportunities to improve service and to inform corrective action, and these need to link to a quality and risk management system and a risk management plan. Policies and procedures are reviewed to ensure they are fit for purpose. | PA Moderate | Reporting Complete | |
| Service providers shall evaluate progress against quality outcomes. | There is no trend analysis of quality data collected and data collection is not utilised to evaluate quality improvement progress. Internal audits are not consistently conducted as scheduled. | Data is collected and analysed with trends identified to evaluate progress across quality outcomes. Internal audits are completed as scheduled. Information gained from quality information collection is utilised to support quality improvement. | PA Moderate | Reporting Complete | |
| Service providers shall develop and implement policies and procedures in accordance with good employment practice and meet the requirements of legislation. | Policies and procedures are overdue for review, references have not been collected for three out of five staff recruited in the 2021-2022 period. | A process is put into place to ensure that policies and procedures are reviewed in a timely manner and that all staff are reference checked prior to commencing employment, in line with the organisation’s policy and procedure requirements. | PA Low | Reporting Complete | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | Staff do not consistently have the opportunity to discuss their performance. | A process is put into place to ensure all staff have the opportunity to discuss their performance, in line with the organisation’s policy and procedure requirements. | PA Low | Reporting Complete | |
| Governance bodies shall ensure service providers’ structure, purpose, values, scope, direction, performance, and goals are clearly identified, monitored, reviewed, and evaluated at defined intervals. | There is no plan in place to make sure that the organisation’s’ structure, purpose, values, scope, direction, performance, and goals are clearly identified, monitored, reviewed, and evaluated at defined intervals. | Strategic planning, when completed, will outline the organisation’s structure, purpose, values, scope, direction, performance, and goals and ensure these are clearly identified, monitored, reviewed, and evaluated at defined intervals. | PA Low | 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 | Three out of eight residents’ files sampled for review did not have routine six-monthly care plan evaluation completed. | Ensure long term care plans are reviewed in the timeframes required by the aged related residential care contract. | 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 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: Surveillance Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Provisional Audit
