Premise details
- Address
- 122 Churchill Drive Crofton Downs Wellington 6035
- Total beds
- 49
- Service types
- Rest home care, Geriatric, Medical
Certification/licence details
- Certification/licence name
- Bupa Care Services NZ Limited - Crofton Downs Care Home
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- Bupa Care Services NZ Limited
- Street address
- Level 2 109 Carlton Grove Road Newmarket Auckland 1023
- Postal address
- PO Box 113054 Newmarket Auckland 1149
- Website
- http://www.bupa.co.nz/
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 |
|---|---|---|---|---|---|
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | (i)The resident meeting minutes reviewed do not evidence follow up and sign off of actions. (ii)External benchmarking is completed; however, there is no evidence to demonstrate a link to quality and risk systems at Crofton Downs. | (i)Ensure that there is evidence of follow up and sign off of actions when completed. (ii)Ensure evidence of link of benchmarking data to quality and risk systems. | PA Low | In Progress | |
| 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. | The facility did not meet all requirements of compliance when assessed for renewal of the BWOF. The team have been proactive in addressing the issues that did not meet compliance; however, at time of audit the facility was yet to obtain a current BWOF. | Ensure the facility obtains and displays a current BWOF. | PA Low | In Progress | |
| Service providers shall evaluate progress against quality outcomes. | (i)There is no evidence to demonstrate progress or sign off of corrective actions from internal audits. (ii)Review of the progress on facility quality goals has not been measured and documented. | (i)Ensure follow up and sign off of corrective actions. (ii)Ensure quality goals are reviewed. | PA Low | In Progress | |
| 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. | Health Quality and Safety Commission notification has not been completed for a pressure injury that has deteriorated over the past months and is now a stage IV. | Ensure that reporting is completed in line with the National Adverse Event Policy. | PA Low | In Progress | |
| 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. | Core training has been completed; however, the attendance registers evidence low completion rates of the required training. There is no evidence to demonstrate that staff who missed initial training had caught up with the required training. | Ensure all staff attend the required training. | PA Low | In Progress | |
| Surveillance methods, tools, documentation, analysis, and assignment of responsibilities shall be described and documented using standardised surveillance definitions. Surveillance includes ethnicity data. | Review of infection data in meeting minutes and graphs displayed for staff does not evidence that infection surveillance includes ethnicity data. | Ensure surveillance includes ethnicity data. | PA Low | In Progress |
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: Certification Audit
Audit date:
Audit type: Partial Provisional Audit
