Premise details
- Address
- 66 Litchfield Street Redwoodtown Blenheim 7201
- Total beds
- 57
- Service types
- Medical, Rest home care, Geriatric
Certification/licence details
- Certification/licence name
- Bethsaida Trust Board Incorporated - Bethsaida Retirement Village
- Current auditor
- The DAA Group Limited
- End date of current certificate/licence
- Certification period
- 24 months
Provider details
- Provider name
- Bethsaida Trust Board Incorporated
- Street address
- 66 Litchfield Street Redwoodtown Blenheim 7201
- Postal address
- PO Box 333 Blenheim 7240
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 |
|---|---|---|---|---|---|
| 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 | The requirements for evaluation and review, including interRAI assessment and update of the residents’ care plan when their needs changed were not met. This included: • Twenty-nine residents were overdue an interRAI assessment at the time of audit. • In eight of eight care plans reviewed the care plan evaluation had not been completed or was incomplete; where an evaluation had been commenced this did not record the degree of achievement towards agreed goals and aspirations. • Three residents whe | Ensure all requirements for evaluation and review are met including: • InterRAI assessments are completed six-monthly and/or when a resident’s needs change. • Care plan evaluation occurs at a minimum of six-monthly and that evaluation documents the degree of achievement towards agreed goals and aspirations. • Care plans are updated in a timely manner to reflect all residents’ needs identified from the assessment process including for all clinical assessment protocols triggered. | PA Moderate | 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 is no RN on night shift in the facility two night shifts a week. | Provide evidence that an RN is rostered 24/7. | PA Moderate | Reporting Complete | |
| A medication management system shall be implemented appropriate to the scope of the service. | Not all elements of the medication management system as implemented meet the expected standard for storage of medications to enable safe administration of medications. · Not all prescribed medication contained a legible label with the required information including the resident’s name and prescription details. · Not all eye drops were labelled with the date of opening and eye ointments had not been discarded thirty days after opening as required. · Individually dispensed and packaged medication | Ensure all aspects of the medication management system meet the required standard including: • Ensure all medication has a legible label with the required information including the resident’s name and prescription details. • Ensure all eye drops are labelled with the date of opening and eye drops and ointments are discarded thirty days after opening if this is specified by the pharmacist. • Ensure medication is only administered to the resident for whom it is dispensed. • Complete the required s | PA Moderate | Reporting Complete | |
| Buildings, plant, and equipment shall be fit for purpose, and comply with legislation relevant to the health and disability service being provided. The environment is inclusive of peoples’ cultures and supports cultural practices. | Not all the tagging and testing and calibration of equipment were current. | Provide evidence that the testing and tagging and calibration of equipment is current. | PA Moderate | Reporting Complete | |
| The frequency and extent of monitoring of people during restraint shall be determined by a registered health professional and implemented according to this determination. | Documentation of the monitoring of bedside rails exceeds the requirement of every two hours. | Provide evidence of the two-hourly monitoring of bedside rails being used as a restraint. | 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. | Not all medication charts included information related to the presence or absence of medication-related sensitivities and/or allergies. | Ensure all residents’ medication charts identify whether medication-related sensitivities and allergies are present or if there are no known allergies. | PA Moderate | In Progress | |
| 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 is no documented IP programme in place approved by the governing body and annual review and reporting has not occurred. | Ensure an IP programme is in place and that this is approved by the governing body and reviewed and reported on annually. | 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. | Analysis of infection surveillance data has not occurred since 2022 and ethnicity data is not included in the infection surveillance reporting. | Ensure analysis of infection surveillance data occurs and that this includes ethnicity data. | 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 | In four of five files reviewed evidence of regular GP review was not sighted. Nursing progress notes documented the reviews had occurred but medical notes from the reviews were not always included in the health file. | Ensure medical or nurse practitioner reviews are documented in the resident’s health record for each visit. | 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 | In five of five files reviewed, the residents’ individual strengths, goals and aspirations were not identified and supports required to meet the residents’ individual goals were not documented. This included goals and supports for both physical and cultural/spiritual needs. | Ensure the assessment process identifies the residents’ individual strengths, goals and aspirations and that these are documented. Ensure care planning documents the supports required to meet the residents’ personally identified goals and that these supports are aligned with their values and beliefs. | 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 | Short-term care planning was not always in place to meet short-term needs. This included for four residents with an identified infection and one resident with a pressure injury. | Ensure short-term care planning is completed for all identified short-term needs. | 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 | In eight of eight files reviewed the residents’ individual strengths, goals and aspirations were not identified and supports required to meet the residents’ individual goals were not documented. This included goals and supports for both physical and cultural/spiritual needs. | Ensure the assessment process identifies the resident’ individual strengths, goals and aspiration for both physical and cultural/spiritual needs. Ensure care planning documents the supports required to meet the resident’s personally identified goals and that these supports are aligned with their values and beliefs. | 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 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
Audit date:
Audit type: Partial Provisional Audit
Audit date:
Audit type: Partial Provisional Audit
Audit date:
Audit type: Surveillance Audit
