Premise details
- Address
- Hokianga Health 163 Parnell Street RD 3 Kaikohe 0473
- Website
- http://www.hokiangahealth.org.nz
- Total beds
- 26
- Service types
- Rest home care, Geriatric, Maternity, Medical
Certification/licence details
- Certification/licence name
- Hokianga Health Enterprise Trust - Hokianga Hospital
- Current auditor
- The DAA Group Limited
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- Hauora Hokianga Trust
- Street address
- 163 Parnell Street RD 3 Kaikohe 0473
- Postal address
- Private Bag Kaikohe 0440
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 |
|---|---|---|---|---|---|
| My complaint shall be addressed and resolved in accordance with the Code of Health and Disability Services Consumers’ Rights. | The complaints register reviewed demonstrated that immediate responses were made to some complainants; however, there are six complaints that have been investigated but remain open in the register as they have not been subsequently followed-up and/or closed out effectively. | Ensure that all complaints are managed in accordance with the Code and that timeframes are effectively met and that the register is updated. | 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. | Education and/or training required for the healthcare assistants including routine mandatory training is not recorded to evidence training has been completed. Attendance records of education sessions are also not being documented and maintained. | Ensure training/education provided is recorded and that staff attendance records are maintained. | PA Low | Reporting Complete | |
| Service providers ensure competent health care and support workers manage medication including: receiving, storage, administration, monitoring, safe disposal, or returning to pharmacy. | Annual medication competencies for RNs are not current and are out of date by six months. | Ensure medication competencies are completed for all staff who are responsible for administering medications. | PA Moderate | Reporting Complete | |
| Service providers shall facilitate safe self-administration of medication where appropriate. | There was no written evidence of assessment for safety of medication self-administration with sign off from the GP, or ongoing assessments to ensure safety. It was reported by the RN on duty that the GP did sign this resident off as being safe to self-administer medication, but they could find where this was written. The patient was very knowledgeable about their medication and was able to demonstrate safety when taking their medication but stated that if they became unwell, they would not be ab | Any resident who wishes to self-administer their own medication have an initial and ongoing assessment documented to confirm they are safe to do so. | PA Low | Reporting Complete | |
| Health care and support workers shall receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures. | There has been no fire drill for staff recorded since October 2020. There is a pre-audit booking arranged for the 5 August 2022. | Ensure a fire drill is held six-monthly as required and that the records are maintained. | PA Low | Reporting Complete | |
| Infection prevention education shall be provided to health care and support workers and people receiving services by a person with expertise in IP. The education shall be: (a) Included in health care and support worker orientation, with updates at defined intervals; (b) Relevant to the service being provided. | There was no current in-service training on IPC in the past year. | Ensure Infection Prevention and Control training is provided relevant to the services as planned with evidence of attendance documented. | PA Low | Reporting Complete | |
| Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services. | The clinical services manager does cover any shifts required and does not leave the facility understaffed; however, staffing of registered nurses, medical and healthcare workers are not adequate to ensure and to sustain appropriate and culturally safe services. | To ensure vacant positions are filled as soon as possible with appropriately skilled staff. | PA Moderate | Reporting Complete | |
| Governance bodies shall evidence leadership and commitment to the quality and risk management system. | There are processes in place to formally report on financial, audit and risk issues to the BOT. The board of trustees is yet to identify what other quality-related information is required to be reported to the BOT, the frequency and process. | The board of trustees to identify what quality information is required to be provided to the board, the timeframe and the reporting process and ensure this is implemented. | 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. | Organisation policies have yet to be updated to include the requirements of Ngā Paerewa (although this is in progress), and includes restraint elimination, guidance related to the care of Pasifika (refer to subsection1.2), and other components. Incident numbers, themes and trends are not being sufficiently reported to the clinical governance committee. The use of restraint is not being communicated to clinical governance or the board of trustees. Health and safety committee meetings are not cons | Continue to update organisation policies and procedures to include Ngā Paerewa requirements. Provide sufficient incident/adverse events to the clinical governance committee to enable analysis and appropriate action be taken to address themes and trends. Ensure the use of restraint is monitored and reported to governance and an elimination strategy implemented. Ensure minutes are consistently recorded for health and safety committee meetings. | PA Moderate | Reporting Complete | |
| Service providers shall understand and comply with statutory and regulatory obligations in relation to essential notification reporting. | Not all applicable events are being reported as required as an essential notification and/or records were not easily available to identify what notifications had occurred and to whom. | Ensure all applicable events are reported to the relevant agencies in a timely manner and that records are retained in relation to these communications. | PA Low | Reporting Complete | |
| Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services. | The service has significant vacancies for medical practitioners which has resulted in gaps covering the roster. The service is working to mitigate the impact of this by advising patients to see acute care at other hospitals or to see their GP in a timely manner. | Continue recruitment processes for medical staff to ensure inpatient services are sufficiently covered. | 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. | Records demonstrating staff have completed orientation requirements were missing from the paper-based and electronic records of four out of eight applicable staff files reviewed who were employed between August 2022 and October 2023. | Ensure all staff are provided with an orientation relevant to their role, and records retained. | PA Low | Reporting Complete | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | Staff performance appraisals are overdue. | Ensure staff performance appraisals are undertaken annually. | PA Low | 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 | The aged-related residential care (ARRC) client at rest home level care audited using tracer methodology was not seen by the GP or NP within five days of being confirmed as requiring rest home level care. The interRAI assessments was not undertaken within 21 days for the ARRC resident audited using tracer methodology. This resident’s care plan is being reviewed and updated; however, this review process is not in synchrony or being informed by the interRAI assessment. Long-term and short-term car | Ensure all ARRC residents are reviewed by a general practitioner or nurse practitioner within five days of being confirmed as requiring long-term aged-related residential care (if not seen within two working days prior). Ensure interRAI assessments are undertaken within 21 days and the information is used to inform the long-term care plan. Ensure short-term care plans and long-term care plans are sufficiently detailed to guide care. Ensure the records related to general practitioner and nurse sp | PA Moderate | Reporting Complete | |
| A medication management system shall be implemented appropriate to the scope of the service. | Sample signatures for the administration of medications was missing in 50% of paper-based medication administration records sampled. The temperature of the medication refrigerator in maternity services is not being monitored | Ensure sample signatures are noted for all staff prescribing and administering medications and medication administration records are completed appropriately. Implement a process to monitor that the temperature of the medication refrigerator in maternity is within the required temperature range. | PA Low | Reporting Complete | |
| Service providers shall facilitate safe self-administration of medication where appropriate. | The required assessment processes have not been implemented to ensure a resident can safely self-administer their own medications. | Ensure the assessment and review processes are implemented for all residents self-administering 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 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
