Premise details
- Address
- 6 Brunner Street Greymouth 7805
- Total beds
- 43
- Service types
- Rest home care, Geriatric, Medical
Certification/licence details
- Certification/licence name
- Dixon House Trust Board (Inc) - Dixon House Rest Home
- Current auditor
- The DAA Group Limited
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- Dixon House Trust Board (Inc)
- Street address
- 6 Brunner Street Greymouth 7805
- Postal address
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. | Not all elements of the quality framework, as described in policy and detailed above, had been fully implemented. | Ensure the quality framework described in policy is fully implemented, and that all quality activities described in policy are completed. Ensure that corrective action planning and quality improvement planning are documented to address shortfalls identified, and that plans include evaluation of improvements. Ensure meeting minutes are sufficiently detailed to evidence what has occurred, what decisions are made, actions required, identify who is assigned responsibility, and that actions are foll | PA Moderate | In Progress | |
| Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services. | Review of the roster showed there were insufficient RNs on duty to meet the needs of the residents as determined by the provider’s safe staffing formula. Inclusion of the CNM in the RN roster meant that the CNM had insufficient time for managerial functions and oversight of clinical services for residents in the service. Recruitment for increased caregiver and RN hours required for an increase in the number of hospital-level residents had not yet begun and funding had not been approved for recru | Provide evidence that the rostered RN hours are in line with the safe staffing formula employed at the facility. Provide evidence that, prior to increasing the number of hospital level residents, there is adequate staffing in line with the staffing formula and that rostered RN hours are sufficient to allow for the CNM to complete managerial functions and have oversight of clinical services. | PA Moderate | In Progress | |
| The physical environment, internal and external, shall be safe and accessible, minimise risk of harm, and promote safe mobility and independence. | The environment maintenance schedule as documented had not been fully implemented and not all urgent maintenance identified had been carried out, resulting in degradation of the environment. There was no safe and appropriate outdoor area for residents to use with shade and seating. Environmental hazards had not all been eliminated or mitigated. | Ensure that the maintenance schedule is implemented. Ensure that there is a safe and appropriate outdoor area for resident use that includes shade and seating. Ensure screens or dividing curtains are available to ensure privacy for individual residents when required. Ensure that outdoor hazards are eliminated or mitigated. | PA Moderate | In Progress | |
| Service providers shall develop and implement policies and procedures in accordance with good employment practice and meet the requirements of legislation. | Seven of ten staff files reviewed had no evidence that police vetting had occurred. | Ensure that police vetting occurs for all new staff and volunteers on employment. | PA Low | In Progress | |
| Service providers shall identify external and internal risks and opportunities, including potential inequities, and develop a plan to respond to them. | There was a risk register in place which had been reviewed and updated. However, not all identified risks had been included, mitigation strategies were not in place for all risks, and not all risks identified as high risk had been reported to or reviewed by the governing body. | Ensure that all risks are included on the risk register, that elimination or mitigation occurs as appropriate, and that all risks identified as high risk are reviewed by the board of trustees. | PA Moderate | In Progress | |
| Service providers shall ensure there are implemented fire safety and emergency management policies and procedures identifying and minimising related risk. | The service had not confirmed with FENZ that the fire evacuation plan will be appropriate for a proposed higher number of non-mobile residents. | Ensure that, prior to increasing the number of hospital level residents, confirmation is sought from FENZ that the fire evacuation plan remains appropriate and that there are sufficient resources and equipment available for the evacuation of the increased number of higher acuities, non-mobile, residents. | PA Low | In Progress | |
| Governance bodies shall have demonstrated expertise in Te Tiriti, health equity, and cultural safety as core competencies. | The service was unable to confirm that the board of trustees had completed training on, and could demonstrate expertise in, Te Tiriti, health equity or cultural safety. | Provide evidence that the board of trustees have completed training which enables them to demonstrate expertise in Te Tiriti, health equity or cultural safety. | PA Low | In Progress | |
| 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 IPCC has not completed specific education in IP and AMS leadership relevant to the role. | Ensure the IPCC completes formal education and ongoing professional development in IP and AMS appropriate to their leadership responsibilities. | PA Low | In Progress | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | Caregivers completed a self-assessment of performance but had not had an annual performance appraisal that included the opportunity to review and discuss their performance as defined in policy. | Ensure that all staff have a performance appraisal that includes the opportunity to review and discuss their performance, as described in policy. | PA Low | In Progress | |
| My complaint shall be addressed and resolved in accordance with the Code of Health and Disability Services Consumers’ Rights. | Acknowledgement of complaints and responses to complaints were not documented. As a result, evidence was not available to confirm that the timeframes for acknowledgement of complaints and responses to complainants required by policy and the Code were met. | Ensure all aspects of complaints management, including the acknowledgement of complaints and reporting of outcomes to complainants, are documented as described in policy and in line with the Code. | PA Low | In Progress | |
| The nutritional value of menus shall be reviewed by appropriately qualified personnel such as dietitians. | The organisation has not yet finalised the dietitian’s review or implemented the recommended updates to dietary menu options. | Provide evidence that the menu has been reviewed by a suitable qualified person such as a dietitian and that any recommendations have been implemented. | PA Low | In Progress | |
| I am informed of the findings of my complaint. | Complaint responses were not documented, complainants did not receive a written response as required by policy, and no evidence was available to confirm complainants were notified of the outcome/findings of their complaint. | Ensure all aspects of complaint management are documented, including written responses to complainants outlining the findings of complaint investigations as required by policy. | 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 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; Partial Provisional Audit
Audit date:
Audit type: Surveillance Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Surveillance Audit
