Premise details
- Address
- 10 Central Takaka Road Takaka 7183
- Total beds
- 30
- Service types
- Rest home care, Geriatric, Maternity, Medical
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 |
|---|---|---|---|---|---|
| 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 | (i). The IP coordinator is part of the practice, and has not attended training outside of the mandatory staff training to support the role across all GBCH services. (ii). Replacement of the dedicated IP portfolio holder across the inpatient services has yet to be confirmed. | (i). Ensure the IP coordinator receives the appropriate training to support the role`s responsibilities. (ii). Ensure there is sufficient, and appropriate resource to support implementation of the IP programme. | 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. | Aged care: (i). Only one scheduled audit had been completed across the period June 2024 to May 2025. (ii). No resident meeting minutes were available to review across the 2024 period. (iii). The last resident satisfaction survey was completed in August 2023 and family survey early November 2022. | (i). Ensure there is an implemented internal audit programme to monitor operational performance. (ii). Ensure there are meeting minutes documented when resident forums do occur. (iii). Ensure annual surveys are completed as per policy. | PA Moderate | 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. | All services: (i). Thirty of thirty-four healthcare assistants have yet to complete restraint training / de-escalation of behaviours and associated competencies. (ii). Twenty-seven of thirty staff have not completed training related to infection control. (iii). Thirty-one of thirty-four healthcare assistants have not completed moving and handling training and associated competency. (iv). Twenty-nine of forty-two RNs have not completed training related to infection prevention. (v). Thirty-three | (i)-(v). Ensure mandatory training and associated competencies are completed as required. | PA Moderate | Reporting Complete | |
| Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided. | There were no signed, completed orientation forms on all nine files reviewed. | Ensure there is evidence held on staff records, demonstrating completion of orientation. | PA Low | Reporting Complete | |
| Service providers shall implement a process to support a safe, timely, seamless transition, transfer, or discharge. | Maternity service: The transfer process in maternity to the secondary service is not consistently arranged and/or completed or documented within a timely manner to ensure the safety and wellbeing of the woman and foetus and/or pēpi. | Maternity service: Ensure the transfer process is consistently implemented and documented within a timely manner to ensure the safety of the woman and foetus and/or pēpi. | PA Moderate | Reporting Complete | |
| A medication management system shall be implemented appropriate to the scope of the service. | (i). Controlled medications were not stored in a locked safe as per legislative requirements. (ii). Not all medications in the controlled medications register had documented weekly checks, or six-monthly quantity stock takes. | (i). Ensure controlled medications are stored as per legislative requirements. (ii). Ensure weekly and six-monthly stock takes are completed on all controlled medications. | 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 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
