Premise details
- Address
- 283 Kennedy Road Onekawa Napier 4112
- Total beds
- 19
- Service types
- Rest home care
Certification/licence details
- Certification/licence name
- Experion Care NZ Limited - Bardowie Retirement Complex
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 24 months
Provider details
- Provider name
- Experion Care NZ Limited
- Street address
- 283 Kennedy Road Onekawa Napier 4112
- Postal address
- 283 Kennedy Road Pirimai Napier 4112
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 |
|---|---|---|---|---|---|
| My service provider shall practise open communication with me. | Nine out of fourteen accident/incident forms reviewed did not indicate that next of kin had been informed. | Ensure that next of kin are notified of any accident/incident as per policy. | PA Low | Reporting Complete | |
| A medication management system shall be implemented appropriate to the scope of the service. | (i) Weekly controlled drug checks have not been completed since October 2021; (ii) Medication fridge temperatures are not monitored; (iii) There is no evidence of medication room temperature monitoring prior to June 2023. | (i) Ensure weekly controlled drug checks are completed as per legislation; (ii - iii) Ensure medication fridge and room temperatures are monitored as per safe medication requirements. | 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 | (i) Care plan evaluations have not been evaluated to include progression towards goals; (ii) Healthcare assistants document changes and concerns in progress notes; however, progress notes of two residents did not reflect RN follow up/review. | (i)Ensure care plan evaluations are fully implemented; (ii) Ensure there is documented evidence of RN review. | PA Low | Reporting Complete | |
| Surveillance methods, tools, documentation, analysis, and assignment of responsibilities shall be described and documented using standardised surveillance definitions. Surveillance includes ethnicity data. | Ethnicity data is not being collected into surveillance methods and data captured around infections | Ensure ethnicity data is collected | PA Low | Reporting Complete | |
| Service providers shall evaluate progress against quality outcomes. | Eight of twenty-eight internal audits reviewed did not have a completion date and signed off. | Ensure that all internal audit corrective actions have a completion date and signed off as complete. | PA Low | Reporting Complete | |
| I shall have the right to make an informed choice and give informed consent. | Three of five resident files reviewed did not evidence signed consent forms. | Ensure all resident files include signed consent forms. | 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 | (i). There were no interventions documented in relation to diabetes management including (but not limited to) signs and symptoms of hypo and hyperglycaemia and management of same, footcare, eye check-ups, HBA1c monitoring requirements for two residents with diabetes. (ii). There were no pain management interventions documented which were identified in the interRAI assessment for one resident with chronic pain. (iii). There were no falls prevention strategies (which were identified in the inter | (i)-(iv). Ensure interventions are documented to ensure sufficient guidance are provided for staff to manage all clinical risks. | 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) One resident did not have blood glucose recordings consistently documented; (ii) Three falls were neurological recordings needed to be completed were not documented for the length of time or at the required intervals required by Bardowie policy and procedure requirements; (iii) Weights are scheduled monthly; however, not all resident files reviewed evidenced monitoring occurred as planned. | (i) Ensure Blood glucose monitoring occurs as per GP or RN instructions; (ii) Neurological observations are taken within the requirements set out in the policy; (iii) monthly weighs were not consistently recorded in two of five files reviewed. | PA Moderate | 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. | The service has not commenced formal collection of staff ethnicity information. | Ensure that staff ethnicity information is being collected. | 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 | (i)Three of five resident files reviewed did not evidence assessments for falls risk, mobility, pain, skin, communication or cognition; (ii)One care plan did not include interventions to manage or monitor insulin-dependent diabetes or accurate mobility interventions; (iii) One resident with ongoing pain requiring controlled drug analgesia did not include pain management strategies; (iv) One resident with addiction treatments in place did not have this referenced or associated risks documented in | (i). Ensure assessments are completed as needed; (ii) Ensure care plans include interventions to support all assessed needs. | PA Moderate | Reporting 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. | The clinical nurse manager had not completed eight hours training annually in relation to managing an aged care facility. | The clinical nurse manager is required to complete eight hours training annually in relation to managing an aged care facility. | PA Low | Reporting Complete | |
| Service providers shall facilitate safe self-administration of medication where appropriate. | There was no documented evidence a medication competency assessment had been completed for the resident self-medicating. | Ensure medication competency assessments are completed as per medication guidelines. | PA Moderate | 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. | (i).Two files did not evidence an initial care plan, (ii) Two of five initial interRAI assessments were not completed within timeframes, (iii) Two resident files reviewed did not have long-term care plans evidenced on the day of audit and one resident did not have a long-term care plan completed within 21 days. | (i) Ensure initial care plans are documented within 48 hours of admission. (ii) Ensure interRAI assessments are completed within contractual timeframes; (iii) Ensure long-term care plans have been completed within 21 days. (iv) Ensure care plans are evaluated six monthly. | PA Moderate | Reporting Complete | |
| The following aspects of the system shall be performed and communicated to people by registered health professionals operating within their role and scope of practice: prescribing, dispensing, reconciliation, and review. | Controlled drugs are delivered weekly and signed in by the pharmacist and HCA. The RN is currently providing no oversite by way of weekly checks; therefore, the service is not meeting safe reconciliation processes. | Ensure a registered nurse is involved in the reconciliation of controlled drugs on delivery by the pharmacist. | PA Moderate | Reporting Complete | |
| A process shall be implemented to identify, record, and communicate people’s medicinerelated allergies or sensitivities and respond appropriately to adverse events. | Allergies were not documented on medication charts for seven of ten medication files reviewed. | Ensure medication allergies of ‘Nil known’ is documented on medication charts | PA Moderate | Reporting Complete | |
| There shall be a clinical governance structure in place that is appropriate to the size and complexity of the service provision. | At an organisational level, there is currently no clinical governance group across the organisation. | Ensure there is a clinical governance group to support the six facilities within Experion Care. | PA Low | Reporting Complete | |
| Governance bodies shall ensure service providers identify and work to address barriers to equitable service delivery. | The service is not collaborating with mana whenua in business planning and service development to improve outcomes and achieve equity for Māori; to identify and address barriers for Māori for equitable service delivery. | Ensure that the service collaborates with mana whenua in business planning and service development to improve outcomes and achieve equity for Māori; to identify and address barriers for Māori for equitable service delivery. | PA Low | Reporting Complete | |
| Service providers shall ensure their health care and support workers can deliver highquality health care for Māori. | There is little documented evidence that staff are provided with up-to-date information on Māori health outcomes and disparities, and health equity. | Ensure that staff are encouraged to participate in learning opportunities that provide them with up-to-date information on Māori health outcomes and disparities, and health equity. | PA Low | Reporting Complete | |
| Governance bodies shall support people receiving services and whānau to participate in the planning, implementation, monitoring, and evaluation of service delivery. | There is little documented evidence that residents and whanau (other than a survey) are in the planning, implementation, monitoring, and evaluation of service delivery. | Ensure the organisation determines and implements how residents and whānau participate in the planning, implementation, monitoring, and evaluation of service delivery. | PA Low | Reporting Complete | |
| Governance bodies shall have meaningful Māori representation on relevant organisational boards, and these representatives shall have substantive input into organisational operational policies. | There is no meaningful Māori representation at a governance level. | Ensure there is meaningful Māori representation at a governance level. | PA Low | Reporting Complete | |
| Service providers shall understand Māori constructs of oranga and implement a process to support Māori and whānau to identify their own pae ora outcomes in their care or support plan. The support required to achieve these shall be clearly documented, communicated, and understood. | Cultural considerations were limited in the care plan reviewed of a Māori resident. | Ensure cultural considerations and pae ora outcomes are included where appropriate in care plans. | PA Low | Reporting Complete | |
| An approved food control plan shall be available as required. | Food temperature monitoring has not been consistently documented on the weekends for the records reviewed (January to September 2024). | Ensure that food temperature monitoring is completed and documented as per standard. | 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 | (i). Blood glucose level monitoring has not been completed twice daily as per care plan for one resident who is diabetic. (ii). When the blood glucose level readings have registered ‘high’ reading on the machine for the same resident, there is no documented follow-up or interventions related to the management thereof by the registered nurse. | (i). Ensure blood glucose level monitoring is completed as per care plan. (ii). Ensure there is registered nurse follow-up with documented management plans to meet the acute changes in healthcare needs of the residents. | PA Moderate | Reporting Complete | |
| A medication management system shall be implemented appropriate to the scope of the service. | Staff have not been consistently documenting the effectiveness / outcome following administration of ‘as required’ medicines. | Ensure that effectiveness of ‘as required’ medicines is documented | 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: Surveillance Audit
Audit date:
Audit type: Certification Audit
