Premise details
- Address
- 50 Beetham Avenue Lytton West Gisborne 4010
- Total beds
- 48
- Service types
- Dementia care, Rest home care, Geriatric, Medical
Certification/licence details
- Certification/licence name
- Beetham HealthCare Limited - Beetham HealthCare
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- Beetham HealthCare Limited
- Street address
- 50 Beetham Avenue Lytton West Gisborne 4010
- Postal address
- PO Box 152 Gisborne 4040
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 |
|---|---|---|---|---|---|
| A medication management system shall be implemented appropriate to the scope of the service. | (i). Medication is taken from the original packaging and left on the medication trolley in the medication room, if a resident is not available at the time of the medication round. (ii). The medication trolley and medication room are not always locked. | (i). Ensure all medications remain in their original packaging, are secured until use, with documentation completed at the time of administration. (ii). Ensure that medication is safely secured when not in use. | PA Moderate | 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. | A process is not yet in place to ensure that all information pertaining to entry and decline rates for all people, including Māori, is routinely analysed. | Ensure a system is implemented that ensures all information pertaining to entry and decline rates for all people, including Māori, is routinely analysed. | PA Low | 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. | The infection prevention and control programme and the antimicrobial stewardship programme has not been reviewed annually as scheduled. | Ensure that the infection prevention and control programme and the antimicrobial stewardship programme is reviewed as scheduled. | PA Low | Reporting Complete | |
| Service providers, shall evaluate the effectiveness of their AMS programme by: (a) Monitoring the quality and quantity of antimicrobial prescribing, dispensing, and administration and occurrence of adverse effects; (b) Identifying areas for improvement and evaluating the progress of AMS activities. | The quality and quantity of antimicrobial prescribing is not monitored. | Ensure that there is consistent monitoring of quality and quantity of antimicrobial prescribing. | PA Low | 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. | (i). A training plan for registered nurses is not documented. (ii). Eight of nine registered nurses do not have a current syringe driver competency. | (i). Document and implement a training plan for registered nurses, with monitoring to confirm that this is completed. (ii). Ensure that there are sufficient registered nurses trained and competent to use syringe drivers. | PA Moderate | Reporting Complete | |
| Surveillance methods, tools, documentation, analysis, and assignment of responsibilities shall be described and documented using standardised surveillance definitions. Surveillance includes ethnicity data. | (i). There is no documented evidence of collation and analysis of data related to infections or of trend analysis. (ii). The service does not include ethnicity data in the surveillance of infections. | (i). Document evidence of collation and analysis of data related to infections and analyse trends to support improvements in service delivery. (ii). Ensure ethnicity is included as part of surveillance data. | PA Low | Reporting Complete | |
| Results of surveillance and recommendations to improve performance where necessary shall be identified, documented, and reported back to the governance body and shared with relevant people in a timely manner. | There is no documented evidence that results of surveillance of infections are reported to the Board, to managers or to staff. | Inform the Board, staff, and managers of the results of surveillance, along with any recommendations to improve performance in a timely manner. | PA Low | Reporting Complete | |
| Governance bodies shall evidence leadership and commitment to the quality and risk management system. | The general manager’s reports to the Board do not evidence reporting of critical resident related information or progress against key performance indicators, including (but not limited to) adverse events, infection, incidents of concern, and anti-microbial stewardship. | Ensure that reports to governance include all aspects of quality and risk, including resident adverse events, infections, and antimicrobial stewardship. | 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. | (i). Review of the quality system processes does not evidence collation of data, trend analysis or benchmarking of adverse events, and therefore does not evidence a documented risk-based approach or critical review to improve service delivery. (ii). Internal audits have not been completed as scheduled. (iii). Review of the meeting minutes does not evidence consistent discussion and review of the service’s quality assurance and risk management programme. | (i). Ensure there is a risk-based approach or critical review of adverse events to improve service delivery. (ii). Ensure internal audits are completed as scheduled. (iii). Ensure meetings evidence review of the service’s quality assurance and risk management programme. | 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: Surveillance Audit
