Premise details
- Address
- 11 Irwell Street Island Bay Wellington 6023
- Total beds
- 60
- Service types
- Rest home care, Intellectual
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
- 36 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 |
|---|---|---|---|---|---|
| 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). Progress notes are not always maintained by a registered nurse following incidents, nurse evaluations, next of kin contact, changes in health care (after discharge from hospital. (ii). Progress notes do not evidence regular registered nurse review of care delivered by caregivers. (iii). Progress notes are general and do not always give an accurate reflection of the resident’s care journey. | (i)-(ii). Ensure registered nurses maintain progress notes and evidence regular review of care delivered by caregivers. (iii). Ensure progress notes evidence an accurate record of the care delivered. | PA Moderate | Reporting Complete | |
| Service providers shall ensure health care and support workers are able to provide a level of first aid and emergency treatment appropriate for the degree of risk associated with the provision of the service. | (i) There are two days on the roster where there are no staff members with a first aid certificate available. (ii) The person responsible for transporting residents did not have a valid first aid certificate. | (i) Ensure there is at least one person with a first aid certificate on each shift. (ii) Ensure the person who is responsible for transporting residents has a current first aid certificate. | PA Low | Reporting Complete | |
| My service provider shall practise open communication with me. | Ten of 12 incident report were not fully completed to evidence family/whānau notification. | Ensure all incident reports evidence family/whānau notification or identify the reason they were not contacted. | PA Low | 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). Short-term care plans are not transferred to long term care plans when interventions become long term. ii). Progress notes do not evidence a RN review of care delivered by caregivers following falls or other minor incidents. | i). Ensure all short-term care plans are reviewed as per policy and long-term issues are transferred to long term care plans. ii). Ensure RN notes evidence regular review of care delivered by caregivers and that the RN follows up with acute issues such as falls. | 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). Three of five resident files reviewed did not evidence initial assessments and initial care plans completed within 24 hours of admission. ii). Three of four resident files who required interRAI reassessments did not have these completed six-monthly. iii). Routine care plan evaluations were not evidenced to be completed in the required timeframes. iv). There was no documented evidence of resident or family/whānau input to care plans or evaluations. | i). - iii). Ensure initial interRAI assessments, reassessments, long term care plans and evaluations are completed within the required timeframes. iv). Ensure care plans evidence resident and family/whānau input. | 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). Changes in residents condition including mobility, cognitive function, nutrition needs, activities of daily living, wound care and increasing challenging behaviours and continence needs have not been updated for three long-term resident files reviewed. ii). A resident who identifies as Māori had a completed initial assessment; however, there is no further information about Māori tikanga or pae ora outcomes. Cultural assessments were evidenced as completed, and care plans lack interventions a | i). Ensure all care plan interventions reflect changes in resident condition. ii). Ensure that care plans are developed with Māori residents and their whānau to include the resident’s pae ora outcomes. | 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). Five residents did not have monitoring of neurological observations completed as per policy. ii). The behaviour monitoring in place for a resident has not been reviewed by the RN. iii). Two residents had no documented follow up from the RN stating the neurological observations were complete. | i). Ensure neurological observations are completed as per policy for all unwitnessed falls. ii - iii). Ensure RN follow up occurs follow up on all adverse events as per policy and monitoring is reviewed to determine a residents further needs. | PA Low | Reporting Complete | |
| A medication management system shall be implemented appropriate to the scope of the service. | i). The room where the medications are stored is not monitored to ensure the temperature is at or below 25 degrees Celsius. ii). The office which holds resident information and medications including controlled drugs is not always secure when there are not staff present. | i). Ensure there is monitoring in place to keep the room at the correct temperature. ii). Ensure the room where medications and resident information are held is secure when there are no staff in the area | 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: Certification Audit
