Premise details
- Address
- 17 Cornwall Park Avenue Epsom Auckland 1051
- Total beds
- 44
- Service types
- Psychogeriatric
Certification/licence details
- Certification/licence name
- Kindred Hospital Limited - Kindred Hospital
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 24 months
Provider details
- Provider name
- Kindred Hospital Limited
- Street address
- 17 Cornwall Park Avenue Epsom Auckland 1051
- Postal address
- 17 Cornwall Park Avenue Epsom Auckland 1051
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 demonstrate routine analysis to show entry and decline rates. This must include specific data for entry and decline rates for Māori. | Ethnicity information is not collected upon enquiry into the service, so entry and decline analysis for Māori cannot be completed. | Collect ethnicity information and analyse entry and decline rates by ethnicity. | PA Low | Reporting Complete | |
| Governance bodies shall appoint a suitably qualified or experienced person to manage the service provider with authority, accountability, and responsibility for service provision. | The oversight of the day-to-day operations of Kindred Hospital do not meet the contractual requirements of the Aged Residential Hospital Specialised Services (ARHSS) agreement Clause D17.5 criteria for manager. Ongoing from the last audit, the service has not demonstrated that there is sufficient time allocated to the clinical manager for them to provide clinical oversight, monitoring of quality and risk management systems, education for staff, and hands on role modelling at Kindred Hospital. | Ensure appointment of a suitably qualified or experienced person into full time position to manage Kindred Hospital with authority, accountability, and responsibility for clinical services, and who meets the contractual requirements of the Aged Residential Hospital Specialised Services agreement Clause D17.5 criteria. | PA Moderate | In Progress | |
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | The annual collation and analysis of incident and accidents have not been completed for 2024 and 2025 as per policy to demonstrate risk-based approach / critical review to improve service delivery. | Ensure critical review and analysis of accident and incidents using a risk-based approach as per policy to improve service delivery. | PA Moderate | In Progress | |
| Service providers shall ensure their health care and support workers have the skills, attitudes, qualifications, experience, and attributes for the services being delivered. | (i)The service continues to have six caregivers that have not completed the required psychogeriatric unit standards as per the requirements of ARHSS agreement D17.11c. (ii)At the time of the audit, the activity coordinator did not have the role requirements in line with the ARHSS agreement D17.7. | (i)Ensure that staff complete the required psychogeriatric unit standards as per the requirements of ARHSS agreement D17.11c. (ii)Ensure that the service employs an activity coordinator meeting the requirements of ARHSS agreement D17.7 | PA Moderate | In Progress | |
| Meaningful activities shall be planned and facilitated to develop and enhance people’s strengths, skills, resources, and interests, and shall be responsive to their identity. | The activities programme was not specific for residents in psychogeriatric hospital care, with a lack of sensory activities and activities to calm residents who display agitated behaviours. | Ensure the activities programme is tailored specifically for residents in psychogeriatric hospital care. | PA Moderate | In Progress | |
| The physical environment, internal and external, shall be safe and accessible, minimise risk of harm, and promote safe mobility and independence. | The main outdoor area is not accessible to residents. | Ensure residents can freely access outdoor areas. | PA Moderate | In Progress | |
| A medication management system shall be implemented appropriate to the scope of the service. | Monthly stocktake including checking of expiry dates of stocked medications was not complete. | Ensure monthly stocktakes are completed as per the policy. | PA Moderate | In Progress | |
| 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)There is insufficient detail in long-term care plans to direct staff in meeting the needs of residents where the interRAI assessment has triggered a risk, such as falls risk, pressure injury risk, mood, behaviour, and undernutrition. (ii)24-hour behaviour management plans are not developed to guide staff in managing residents over the 24-hour period. (iii)Neurological observations following unwitnessed falls were not completed according to the policy in four of four records of unwitnessed fa | (i)Ensure long-term care plans are detailed to direct staff in all required interventions to meet the needs of residents. (ii)Ensure care plans include behaviour management plans that guide staff in managing residents over the 24-hour period. (iii)Complete neurological observations as per the policy following unwitnessed falls. | PA Moderate | In Progress | |
| 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. | (i)Four incidents related to episodes of resident physical aggression to other residents / staff do not have a corresponding incident report completed for the other resident / staff. (ii)Two medication related incidents did not demonstrate robust follow-up and corrective actions to reduce preventable harm. | (i)Ensure that incident and accident reports are completed for all residents and staff involved and affected. (ii)Ensure that robust follow-up of incidents and accidents to reduce preventable harm. | PA Moderate | In Progress | |
| 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. | The two-yearly mandatory training schedule has not been completed as per policy. | Ensure that training is completed as per policy. | PA Low | In Progress | |
| Service providers shall conduct comprehensive reviews at least six-monthly of all restraint practices used by the service, including: (a) That a human rights-based approach underpins the review process; (b) The extent of restraint, the types of restraint being used, and any trends; (c) Mitigating and managing the risk to people and health care and support workers; (d) Progress towards eliminating restraint and development of alternatives to using restraint; (e) Adverse outcomes; (f) Compliance w | Six-monthly reviews of all restraint practice were not completed as per the policy. | Ensure there is six-monthly quality review of all restraint practice. | 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 | (i)Review of four of ten wound care plans and assessments showed a deterioration in wounds, with no change in the management of the wound. (ii)Wound assessments do not include photographs taken at regular intervals to assist with evaluation of the progress in all ten wound assessments reviewed. | (i)Where progress of wounds is not as expected, ensure the management plan is reviewed and adjusted. (ii)Take regular photographs of wounds to assist in evaluating the progress. | PA Moderate | In Progress | |
| Monitoring restraint shall include people’s cultural, physical, psychological, and psychosocial needs, and shall address wairuatanga. | Care plans and monitoring records did not include all aspects staff were to monitor, including cultural, physical, psychosocial, psychological and wairuatanga. | Ensure care plans are sufficiently detailed to guide staff in monitoring requirements and monitoring records show all requirements are monitored. | PA Moderate | In Progress | |
| Service providers shall ensure that there is a pandemic or infectious disease response plan in place, that it is tested at regular intervals, and that there are sufficient IP resources including personal protective equipment (PPE) available or readily accessible to support this plan if it is activated. | At the time of the audit, there were no sufficient PPE resources in stock to ensure safe and effective management of an outbreak. | Ensure that there are adequate supplies of PPE in stock to ensure safe and effective management of an outbreak. | PA Moderate | In Progress | |
| Each person’s room shall have at least one external window, providing natural light, and appropriate ventilation and heating. | Five resident rooms (numbers 19, 20, 22, 24 and 28) do not have an external window, but have a window to either a corridor or another room. | Ensure all resident rooms have an external window. | PA Moderate | In Progress | |
| My complaint shall be addressed and resolved in accordance with the Code of Health and Disability Services Consumers’ Rights. | (i)There is no evidence that all complaints received have been logged on the complaints register. (ii)There is no documented evidence of quality improvement and/or corrective action plan in line with one external complaint received in July 2025. | (i)Ensure all complaints are logged on the complaints register as per policy. (ii)Ensure that quality improvement and/or corrective action plan are completed and implemented as per policy following complaints. | PA Moderate | In Progress | |
| Surveillance methods, tools, documentation, analysis, and assignment of responsibilities shall be described and documented using standardised surveillance definitions. Surveillance includes ethnicity data. | There is no documented evidence to show implementation of the outbreak management process in relation to the July 2025 Covid-19 outbreak. | Ensure implementation of the outbreak process for identified outbreaks, including notification to relevant authorities. | PA Low | In Progress | |
| The nutritional value of menus shall be reviewed by appropriately qualified personnel such as dietitians. | The summer menu was not in use at the time of the audit. | Ensure the correct seasonal menu is provided. | PA Low | In Progress | |
| Alternative essential energy and utility sources shall be available, in the event of the main supplies failing. | There is no contingency plan in place in the event of a power outage for supply of a generator. | Ensure there is a formal agreement in place for the supply of a generator in the event of a power outage. | PA Low | In Progress | |
| Service providers shall ensure that the environment is clean and there are safe and effective cleaning processes appropriate to the size and scope of the health and disability service that shall include: (a) Methods, frequency, and materials used for cleaning processes; (b) Cleaning processes that are monitored for effectiveness and audit, and feedback on performance is provided to the cleaning team; (c) Access to designated areas for the safe and hygienic storage of cleaning equipment and chemi | (i)There is no clear separation of clean and dirty areas in the sluice room to minimise the risk of cross contamination. (ii)There are no clearly documented processes for disinfection / sterilisation of communally used equipment. (iii)There is insufficient evidence to show that the cleaning practices meet accepted infection control processes to minimise cross contamination between residents’ rooms and communal toilets and showers. (iv)There are no colour coding process being implemented with | (i)Ensure that there is clear identification of clean and dirty areas in the sluice room to minimise risk of cross contamination. (ii)Ensure there are processes in place for sterilisation/disinfection of communally used equipment. (iii)Ensure cleaning practices meet accepted infection control processes. (iv)Ensure implementation of the cleaning policy. (v)Ensure there are documented processes for daily and periodic cleaning. (vi) Ensure there is a documented cleaning schedule in the kitchen, | PA Moderate | In Progress | |
| Service providers shall implement systems to determine and develop the competencies of health care and support workers to meet the needs of people equitably. | There are no registered nurses that have completed syringe driver training and competency. | Ensure that the service has registered nurses who have completed syringe driver training and competency to meet the needs of the residents. | 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: Partial Provisional Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Partial Provisional Audit
