Premise details
- Address
- 10 Central Takaka Road Takaka 7183
- Total beds
- 29
- Service types
- Geriatric, Maternity, Medical, Rest home care
Certification/licence details
- Certification/licence name
- Nelson Bays Primary Health Trust - Golden Bay Community Health
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- Nelson Bays Primary Health Trust
- Street address
- 10 Central Takaka Road Takaka 7183
- 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 |
|---|---|---|---|---|---|
| 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 equipment available did not comply with national and international best practice guidelines. | Ensure appropriate equipment is available to comply with best practice guidelines. | PA Moderate | Reporting Complete | |
| Surveillance activities shall be appropriate for the service provider and take into account the following: (a) Size and complexity of the service; (b) Type of services provided; (c) Acuity, risk factors, and needs of the people receiving services; (d) Health and safety risk to, and of, the workforce; (e) Systemic risk to the health and disability system as a whole. | Surveillance of health-care associated infections in the maternity service are not captured, analysed, or reported. | Ensure surveillance of health-care associated infections in the maternity service are captured, analysed, and reported. | PA Low | Reporting Complete | |
| All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal shall comply with current legislation and guidelines. | There was no evidence the fridge in the whānau room that stores milk and whānau food, and fridges in some of the rooms of the rest home residents were checked and had temperatures recorded on a regular basis. | Ensure temperatures of all fridges are monitored and recorded on a regular basis. | PA Low | Reporting Complete | |
| Care or support plans shall be developed within service providers’ model of care. | There was not interventions documented to guide care staff around the oral requirements of a rest home level resident receiving ongoing dental care. | Ensure care plan interventions are current and reflective of all short term/ acute needs. | PA Low | Reporting Complete | |
| Each episode of restraint shall be documented on a restraint register and in people’s records in sufficient detail to provide an accurate rationale for use, intervention, duration, and outcome of the restraint, and shall include: (a) The type of restraint used; (b) Details of the reasons for initiating the restraint; (c) The decision-making process, including details of de-escalation techniques and alternative interventions that were attempted or considered prior to the use of restraint; (d) If | Restraint monitoring had not taken place for five residents with bed rails, and one resident with bed rails and a lap belt. | Ensure restraints are monitored according to the timeframes detailed in policy and as per individual resident’s risk assessment. | PA Moderate | 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. | i). One rest home file and one hospital file did not have the initial interRAI assessment completed within the appropriate timeframe. ii). One rest-home file did not have the initial care plan completed within the required timeframe. iii). One hospital file, and one rest-home file did not evidence the six monthly interRAI reassessment to be completed on time. iv). One of two hospital level long-term care-plans were not completed within the expected timeframe. | i). – iv) Ensure all initial assessments, interRAI assessments and care-plans are completed within required timeframes. | PA Moderate | Reporting Complete | |
| Service providers shall implement systems to determine and develop the competencies of health care and support workers to meet the needs of people equitably. | (i). Four HCAs and one RN employed in the last nine months have not completed restraint competencies or restraint training, infection control training including PPE competencies, and Te Tiriti/tikanga training at orientation and since commencement of employment. (ii). Two HCAs employed for longer than 12 months had competencies and training last completed in June 2022 related to correct use of PPE, cultural safety, restraint for staff employed more than 12 months. | (i)-(ii) Ensure competencies and training topics related to compulsory competencies are completed as required. | PA Low | Reporting Complete | |
| I shall give informed consent in accordance with the Code of Health and Disability Services Consumers’ Rights and operating policies. | A signed general consent form was not present in the aged care resident records reviewed. | Ensure the signed informed consent form is available and accessible at all times. | PA Low | Reporting Complete | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | Two HCAs employed for longer than 12 months did not have a performance appraisal on file for 2023. | Ensure performance appraisals are completed annually for all staff. | PA Low | Reporting Complete | |
| A medication management system shall be implemented appropriate to the scope of the service. | The effectiveness of PRN medications administered is not consistently documented. | Ensure the effectiveness of PRN medications administered is consistently documented. | 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: Surveillance Audit
