Premise details
- Address
- 57 Pah Road Epsom Auckland 1023
- Total beds
- 27
- Service types
- Rest home care
Certification/licence details
- Certification/licence name
- The Greenwoods House Limited - Epsom South Retirement Home
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- The Greenwoods House Limited
- Street address
- 57 Pah Road Epsom Auckland 1023
- Postal address
- PO Box 68744 Victoria Street West Auckland 1142
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 medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines. | Examples of poor practice were identified when observing a staff member giving medication to a number of residents at lunchtime. This included tearing off all blisters for all residents who had lunchtime medication prescribed prior to giving them to the individual resident and leaving medication on top of the trolley unattended. | Ensure staff follow correct medication procedures and guidelines. | PA Moderate | Reporting Complete | |
| A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented. | Meeting minutes sighted did not document the outcomes of the corrective action plans | Ensure there is documented evidence of resolution of issues when corrective action plans are put in place. | 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. | There was insufficient evidence in staff meeting minutes reviewed of discussion around data, use of trend analysis, or of learnings from discussion used to improve services. | Ensure meeting minutes evidence improvements made to services as a result of discussion and use of corrective action planning. | 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 | i). Two residents whose records were reviewed, did not have safety plans documented for challenging behaviours. ii). Two resident files for residents with diabetes did not document: a). Signs and symptoms of hyper glycaemia or hypoglycaemia; b). Expected ranges of blood sugar levels; c). Interventions of how to manage if the blood sugar readings were out of the expected ranges; and d). Management of a diabetic emergency. | i). & ii). Ensure all resident care plans have interventions documented to manage all resident individual needs. | 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 | i). The progress notes do not record that the clinical lead has observed or talked with the resident in the interim. ii). Two resident files did not evidence documentation in the notes of significant incidents. One resident for example, had two incidents documented on incident forms (for a fall, and an admission to hospital via ambulance), with the clinical lead documenting the issues to the GP and the management team in emails, but with no documentation in the resident record itself. iii). One | i)- iii). Ensure that the clinical lead (registered nurse) documents comprehensive progress notes according to policy and best practice. | PA Moderate | Reporting Complete | |
| A medication management system shall be implemented appropriate to the scope of the service. | The effectiveness of ‘as required’ medication when given is not documented in two resident records sighted. | Document the effectiveness of ‘as required’ medication when given. | PA Moderate | 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. | Corrective action planning is not in place when clusters of infection or a large number of infections is identified. Note that quarterly and trend analysis would help staff and managers to identify issues and could contribute to interventions put in place to decrease numbers and types of infections. | Implement corrective action plans to improve infection rates and outcomes for residents. | PA Moderate | 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: Provisional Audit
