Premise details
- Address
- 25 Aynsley Terrace Hillsborough Christchurch 8022
- Total beds
- 28
- Service types
- Physical, Intellectual, Rest home care
Certification/licence details
- Certification/licence name
- Kowhai Resthome (2002) Limited - Kowhai Rest Home
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- Kowhai Resthome (2002) Limited
- Street address
- 56 Rossington Drive West Melton Christchurch 7676
- 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 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. | Less than 50% of staff have attended required training in 2024 and 2025. | Ensure staff complete required training as scheduled. | PA Low | In Progress | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | Three of three staff files where annual appraisals were required identified that annual appraisals are overdue. | Ensure annual appraisals are completed as scheduled. | PA Low | In Progress | |
| A medication management system shall be implemented appropriate to the scope of the service. | Ten of ten medication charts photos had not been reviewed as required. | Ensure resident photos are updated at intervals according to electronic medication management system policy. | PA Moderate | 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. | (i). The caregiver/ cook had a performance appraisal completed to their role as a cook in 2024; however, did not have a job description, or a variation to their second role on file. (ii). The job description for one cook is not signed. (ii). The diversional therapist had no job description on file (started June 2024). | (i)-(iii). Ensure each employee have a signed job description on file. | PA Low | 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. | There was one weekday afternoon shift and one weekend afternoon shift where there was no staff with a current first aid certificate. | Ensure there is a staff member on each shift with a current first aid certificate. | 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). There is no evidence of evaluation of the care plan against the goals. (ii). There is no evidence that advance directive plans are reviewed during care planning, and they have been reviewed by the GP for over the last 18 months. | (i). Ensure care plans include evaluation against the persons goals and aspirations. (ii). Ensure evidence are documented that advance directives are reviewed as required by the policy. | PA Low | Reporting Complete | |
| Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided. | One cook and one diversional therapist did not have completed orientation documents on file. | Ensure each employee staff file evidence completion of their orientation. | PA Low | Reporting Complete | |
| The nutritional value of menus shall be reviewed by appropriately qualified personnel such as dietitians. | A review of the menu by a qualified dietitian has not been undertaken for over three years. | Ensure a menu review is completed biannually as per the current food control plan. | PA Low | Reporting Complete | |
| Alternative essential energy and utility sources shall be available, in the event of the main supplies failing. | The service does not currently have access or arrangements in place to access a generator. | Ensure the service arranges access to a generator in the event of an emergency resulting in a power outage | PA Low | Reporting Complete | |
| All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal shall comply with current legislation and guidelines. | Between April 2024 and December 2024 there were gaps were three to six days with no documented records of temperature checks for three freezers. | Ensure that the kitchen fridge and freezer temperatures are documented daily as required in the food control plan. | PA Low | Reporting Complete | |
| Service providers shall ensure the quality and risk management system has executive commitment and demonstrates participation by the workforce and people using the service. | (i). Not all current updated infection control policies are in circulation. (ii). Disaster management and emergency preparedness folder has last been reviewed in 2021. | (i)-(ii). Ensure the most recent policies developed by the external consultant are in circulation and accessible. | PA Low | Reporting Complete | |
| Governance bodies shall ensure service providers’ structure, purpose, values, scope, direction, performance, and goals are clearly identified, monitored, reviewed, and evaluated at defined intervals. | There is no evidence that directors participate in a review of business plan goals at defined intervals. | Ensure business plan goals are monitored and evaluated at defined intervals. | PA Low | In Progress | |
| 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. | Visual observation and review of environmental audits identified issues with a large area black mould on the ceiling, and call bell issue in a communal bathroom. This was first identified in January 2025. Some repairs to the building were also required. | Develop a corrective action plan and complete repairs and maintenance issues identified in the January 2025 environmental audit. | PA Moderate | In Progress | |
| Governance bodies shall appoint a suitably qualified or experienced person to manage the service provider with authority, accountability, and responsibility for service provision. | The facility manager (RN) has not had previous experience as a manager of a rest home and has not completed related professional development. | Ensure the facility manager completes relevant professional development. | PA Moderate | In Progress | |
| Governance bodies shall evidence leadership and commitment to the quality and risk management system. | Weekly reports have not been consistently provided to both directors with all aspects of quality and risk included in the reports. | Ensure comprehensive weekly reports are provided as per schedule to both directors. | 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 | There were insufficient interventions to guide staff on current care needs in three of five files reviewed. | Ensure all care plan interventions are current, reflect the assessed needs of residents, and are available to guide care staff. | PA Moderate | In Progress | |
| A medication management system shall be implemented appropriate to the scope of the service. | i). Daily temperatures of the medication room and fridge have not been consistently recorded. ii). Seven out of ten medication charts reviewed and/or progress notes did not have effectiveness of PRN medications recorded following administration of the medication. iii). A short course of medication (treatment of a fungal rash) was still being administered two weeks after the stop date. | i). Ensure temperatures of the medication room and fridge are recorded daily. ii). Ensure effectiveness of PRN medications is recorded. iii). Ensure short course medications are stopped as per GP charting. | PA Moderate | In Progress | |
| Service providers shall identify external and internal risks and opportunities, including potential inequities, and develop a plan to respond to them. | i). Corrective actions do not always identify details of required actions, progress or of a timely resolution. ii). Corrective actions have not been documented for adverse survey responses. iii). Survey results have not been communicated to residents, staff or directors. | i). Ensure corrective actions details required actions, progress and resolution. ii). Document corrective actions where opportunities for improvement are identified from surveys. iii). Ensure results of surveys are communicated to residents, staff and directors. | PA Moderate | In Progress | |
| 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 | Monitoring of care is not always documented as being completed as per plans. This included completion of neurological observations, frequency of dressings, and repositioning charts. | Ensure that monitoring of care is documented and completed as per care planning. | 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. | The FM was unaware of the severity assessment code (SAC) reporting procedures. They had reported a recent fracture on a Section 31 form but not a SAC report to the Health Quality and Safety Commission. | Ensure the facility manager develops an understanding of SAC reporting requirements and implement. | PA Low | 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 | Not all documentation was completed in a timely manner including an initial and ongoing interRAI assessments, and evaluation of long-term care plans. | Ensure that interRAI assessments and care plans are completed as per contract in a timely manner. | PA Moderate | In Progress | |
| My complaint shall be addressed and resolved in accordance with the Code of Health and Disability Services Consumers’ Rights. | i). Three written complaints have not been documented on the complaints register. ii). Three complaints submitted by residents do not evidence associated documentation, follow-up or resolution. | i). Ensure all complaints are documented on the complaints register. ii). Ensure all complaints are actioned in accordance with the Code. | PA Moderate | In Progress |
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: Surveillance Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Surveillance Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Surveillance Audit
