Premise details
- Address
- 66 Litchfield Street Redwoodtown Blenheim 7201
- Total beds
- 57
- Service types
- Medical, Geriatric, Rest home care
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 |
|---|---|---|---|---|---|
| My service provider shall design a Pacific plan in partnership with Pacific communities underpinned by Pacific voices and Pacific models of care. | The organisation uses external company policies. There is a reference policy related to the Ministries Pacific plan. However, they have not formulated a Pacific plan with input from the local Pacific community. | A Bethsaida Pacific plan be developed in partnership with the local Pacific community, underpinning the voice of Pacific people and their models of care. | 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. | An electronic quality system from an external provider is in use. Review showed that not all audits were being completed as per the schedule. There is a hazard risk register; however, business risks are not all covered in the register. The Board does not routinely review the risk register. Minutes of all scheduled meetings were not all available. Minutes have a space for corrective actions; however, these were not always completed and evidence of these being closed off was not always appare | All audits be undertaken as per the audit calendar. The hazard risk register be updated with a view to add business risks and the register be reviewed by the board. All meetings be held as per the meeting schedule. | PA Moderate | Reporting Complete | |
| Service providers shall follow the National Adverse Event Reporting Policy for internal and external reporting (where required) to reduce preventable harm by supporting systems learnings. | There is a good culture of reporting incidents onto an electronic system. However, there was evidence that not all events had documentation of the completion of investigation and closure. | All incidents have a documented investigation which is complete, and a closure date. | 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. | There are good opportunities for training for all staff. However, the documentation of completion of training showed gaps, especially the RNs. | All staff undertake the required training and this is evidenced in the organisation’s training record spreadsheet. | 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. | Four residents admitted in the last eight months did not have an interRAI assessment and long-term care plan completed within the contractually required timeframe. Two long-term residents did not have an interRAI assessment six-monthly as required by contract. Evidence was missing of the updating of a resident’s care plan when they had returned from hospital as well as there being no short-term care planning for their changed needs. | Ensure that all residents have an interRAI assessment and long-term care plan completed within 21 days of admission, and long-term residents have an interRAI assessment completed at a minimum of six-monthly as required by the provider’s contract with Health New Zealand. All residents care plans be current with information following return from hospital and having short-term care plans in place. | PA Moderate | 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 seven out of eight files reviewed, the resident’s individual strengths, goals and aspirations were not identified and the supports required to meet their personal goals were not documented. This included goals and supports for both physical and cultural/spiritual needs. | Ensure the care plan is personalised and identifies the residents' personal goals, and that the supports required to achieve their goals are documented. | 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 | In three of eight files reviewed, the care plan had not been updated to reflect the resident's current needs. In eight of eight files reviewed, evidence of regular GP review was not sighted. | Ensure that each resident's care plan is updated when their needs change and that strategies are identified to address all clinical assessment protocols (CAPs) triggered in the interRAI assessment. Ensure notes from the regular GP reviews are incorporated into the resident’s file. | PA Moderate | Reporting Complete | |
| There is an IP role, or IP personnel, as is appropriate for the size and the setting of the service provider, who shall: (a) Be responsible for overseeing and coordinating implementation of the IP programme; (b) Have clearly defined responsibility for IP decision making; (c) Have documented reporting lines to the governance body or senior management; (d) Follow a documented mechanism for accessing appropriate multidisciplinary IP expertise and advice when needed; (e) Receive continuing education | The clinical nurse manager, who is the designated infection prevention coordinator, had not completed training in infection prevention and antimicrobial stewardship relevant to the role. | Ensure the infection prevention coordinator completes training relevant to the role. | 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. | Standardised definitions were not being used when reporting infections. Data did not include ethnicity. | Ensure standardised definitions are used when reporting infections. Ensure surveillance data includes ethnicity. | PA Low | Reporting Complete | |
| My service provider shall work in partnership with Pacific communities and organisations, within and beyond the health and disability sector, to enable better planning, support, interventions, research, and evaluation of the health and wellbeing of Pacific peoples to improve outcomes. | There has been contact through a board member with Pacific community contacts; however, there was no evidence of this being developed into a partnership to support the organisation. | The organisation connects with local Pacific communities and organisations to better understand their needs and support and improve outcomes for their people. | 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
Audit date:
Audit type: Certification Audit
