Premise details
- Address
- 11 Irwell Street Island Bay Wellington 6023
- Total beds
- 60
- Service types
- Rest home care
Certification/licence details
- Certification/licence name
- Nicolson Rest Home Limited - Irwell Rest Home
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 24 months
Provider details
- Provider name
- Nicolson Rest Home Limited
- Street address
- 11 Irwell Street Island Bay Wellington 6023
- 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 identify external and internal risks and opportunities, including potential inequities, and develop a plan to respond to them. | (i). Four of four medication incidents do not document follow up with staff concerned and/or learning process for staff. (ii). One complaint regarding a staff member ‘pulling on a resident’s face cheeks’ has no documented follow up. (iii). Four complaints for 2024/25 care related; there is no documented follow up or learning experience for staff. | (i). – (iii). Ensure that risks are reviewed and issues identified are evidenced as being followed up and include an action plan. | PA Moderate | Reporting Complete | |
| Service providers shall ensure there are implemented fire safety and emergency management policies and procedures identifying and minimising related risk. | The fire exit pathway for residents that connects to the assembly point in the driveway was obstructed by a vehicle parking bay. On the day of the audit there was a mobility van parked. | Ensure that there is a clear pathway for safe and effective evacuation of residents in case of emergency to the assembly point in the car park. | PA Moderate | In Progress | |
| 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 | Five wound care plans reviewed do not demonstrate wound progress evaluation at dressing change. | Ensure evaluations are documented, and progression towards healing is evidenced. | PA Moderate | Reporting Complete | |
| Where required by legislation, there shall be a Fire and Emergency New Zealand- approved evacuation plan. | There was no evidence of evacuation drills being completed to meet the requirements of the evacuation plan. | Ensure fire evacuation drills are evidenced as completed. | PA Moderate | Reporting Complete | |
| Service providers shall follow the National Adverse Event Reporting Policy for internal and external reporting (where required) to reduce preventable harm by supporting systems learnings. | Two pressure injuries and one fall with fracture did not have evidence of an incident/ accident form being completed. | Ensure that all identified incidents and accidents are documented according to policy using the incident form process. | PA Low | Reporting Complete | |
| Service providers shall ensure the skills and knowledge required of each position are identified and the outcomes, accountability, responsibilities, authority, and functions to be achieved in each position are documented. | The job descriptions for the activity coordinator, the registered support person, and the quality improvement officer are for the caregiver role, and do not describe the role they undertake. | Ensure required employment documentation is in place for staff reflecting roles they work. | 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. | (i). Staff education around infection control is provided by staff accessing policies and signing that they have read and understood. Staff inform that videos have been made available to staff, as well as hand washing audits, but these have not been documented. (ii). There is no documented evidence of feedback or education to staff when there was a spike of six UTIs in January 2025. | (i). Ensure that education is provided by a person with expertise in infection control. (ii). Ensure an action plan is developed when infection control issues arise as part of the quality improvement process. | PA Low | Reporting Complete | |
| Service providers demonstrate routine analysis to show entry and decline rates. This must include specific data for entry and decline rates for Māori. | Routine analysis of entry and decline rates does not include specific data for entry and decline rates for Māori. | Ensure that analysis includes specific data for entry and decline rates for Māori. | PA Low | 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). Three of seven admission initial assessments and care plans have not been completed within 24hours. (ii). Two of four interRAI assessments, and two long-term care plans have not been completed within three weeks of admission. (iii)Three activity assessments and care plans have not been completed within three weeks of admission. Two activity care plans were not reviewed at least six-monthly. (iv). There is one overdue interRAI re-assessment and two overdue care plan evaluations. | (i)-(iii). Ensure that all assessments and care plans are completed in line with policy and contractual requirements. (iv). Ensure that assessments and care plan evaluation are completed as scheduled. | PA Low | Reporting Complete | |
| In implementing care or support plans, service providers shall demonstrate: (a) Active involvement with the person receiving services and whānau; (b) That the provision of service is consistent with, and contributes to, meeting the person’s assessed needs, goals, and aspirations. Whānau require assessment for support needs as well. This supports whānau ora and pae ora, and builds resilience, self-management, and self-advocacy among the collective; (c) That the person receives services that remov | (i). There were no short-term care plans for short-term needs for two residents with infections; one with a rash and one for monitoring post pacemaker insertion. (ii). The wound care plans reviewed do not identify category of pressure injuries and have not been updated with district nurse plan of care. Five of five wound care plans reviewed do not demonstrate comprehensive assessment at each dressing change to inform the management plan. (iii). There is no documented 24/7 RN oversight for one | (i)-(ii). Ensure that short-term care plans are developed for short-term needs and wound care plans are detailed. (iii). Ensure there is registered nurse input and oversight documented in resident records. (iv)-(v). Ensure that observations are completed as per care plan and clinical risk. (vi). Ensure clinical follow up of out-of-range blood glucose levels. | PA Moderate | Reporting 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. | (i). Test and tag of electrical equipment and equipment calibration indicates that checks were due 24 April 2022. (ii). There is no evidence that medical equipment including BP machine and thermometers, have been calibrated. (iii). Chair weighing scale has been out of action since November 2024, with no replacement. Residents have not been weighed since then, impacting on clinical risk for monitoring of residents. Calibration of the chair weigh scale indicates that a check was due 24 April 202 | (i)-(ii). Ensure that equipment is fit for purpose, with electrical and calibration checks completed to comply with legislative and service delivery requirements. (iii). Ensure that there is a weighing scale available to weigh the residents. (iv). Ensure that there is adequate pressure relieving equipment for the care requirements. | PA Moderate | 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. | There is no RN cover for when the RN is on leave to meet the ARRC contract (D17.1). | Ensure there is clinical leadership and support available to staff to meet the ARRC contract. | PA Low | Reporting Complete | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | (i). The registered nurse appraisal is a scope of practice document. The document has not been fully completed and does not reflect an appraisal process. (ii). The RN scope of practice document has been signed off by a non-clinical person. | (i). Ensure that the RN appraisal document reflects role performance, opportunities to improve, and future goals. (ii). Ensure that the RN appraisal is undertaken by a clinical person. | PA Low | Reporting Complete | |
| A medication management system shall be implemented appropriate to the scope of the service. | (i). Weekly controlled drug checks have not been consistently completed. (ii). Three medication charts have no allergies documented. (iii). Three medication charts do not have photos. | (i). Ensure weekly stock check of controlled drugs is consistently completed. (ii)-(iii). Ensure all the medication charts have photo identification and allergies documented as per policy and legislative requirement. | 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. | There was no evidence of training sessions being held. Policies have been provided for staff to read. | Ensure that the training programme demonstrates a system of learning and development for staff to provide high quality services. | PA Low | Reporting Complete | |
| Surveillance methods, tools, documentation, analysis, and assignment of responsibilities shall be described and documented using standardised surveillance definitions. Surveillance includes ethnicity data. | Ethnicity is not yet collected as part of infection surveillance. | Ensure that ethnicity data is linked to infection surveillance. | PA Low | Reporting Complete | |
| I shall have the right to make an informed choice and give informed consent. | There are no signed admission agreements on file for three residents (one hospital and two rest home). | Ensure there are signed admission agreements in all resident files. | 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 | (i). Four resident care plans for diabetes management (including one insulin dependent) did not have interventions to guide staff in the delivery of care including monitoring requirements, reportable ranges, signs and symptoms of hypo and hyperglycaemia and management thereof. (ii). Assessments, care planning and evaluation of five short-term care plans and three long-terms care plans and evaluations were completed by the healthcare assistant (registered nurse support), contrary to ARRC agreemen | (i). Ensure care plans have detailed interventions documented to provide guidance to staff on the management of care. (ii). Ensure assessments and each care plan is developed, documented, and evaluated by the registered nurse. (iii)-(iv). Ensure interRAI assessments inform the care plan and CAP triggers are reflected in the care plan. | PA Moderate | Reporting Complete | |
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | (i). Staff meetings have not consistently been evidenced as being held as scheduled. (ii). There is no documented evidence in the meeting minutes of feedback to staff around the quality plan, and quality activities including incidents, accidents and restraint. | (i). Ensure that staff meetings are held according to the schedule. (ii). Ensure that there is evidence of the sharing of quality information with staff. | PA Low | Reporting Complete | |
| Service providers shall understand and comply with statutory and regulatory obligations in relation to essential notification reporting. | (i). Section 31 notification or SAC reports were not evidenced for one stage III pressure injury and one fall with fracture. (ii). There were no Section 31 notifications completed when there was no RN cover, when the RN was on leave. | (i). Ensure that essential reporting is completed as required. (ii). Ensure Section 31 notifications are completed when there is no RN cover. | PA Low | Reporting Complete | |
| People receiving services shall be supported to access their communities of choice where possible. | There are planned van outings each week that allow residents to access the community. The facility van does not have a hoist and therefore only mobile residents able to navigate the stairs can go out in the outing. Residents who use walkers or wheelchairs are unable to engage in the outings. | Ensure an equitable service is supported for all residents to access communities of choice. | 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 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
