Premise details
- Address
- 14 Manor Park Road Manor Park Lower Hutt 5019
- Total beds
- 85
- Service types
- Psychogeriatric, Mental health
Certification/licence details
- Certification/licence name
- W. Fullerton Investments Limited - Manor Park Private Hospital
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 24 months
Provider details
- Provider name
- W. Fullerton Investments Limited
- Street address
- Manor Park Private Hospital 14 Manor Park Road Manor Park Lower Hutt 5019
- Postal address
- PO Box 45160 Waterloo Lower Hutt 5042
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 |
|---|---|---|---|---|---|
| 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). Three of three post fall events did not include any neurological observations for residents who had an unwitnessed fall. (ii). Two of three post falls events did not record any skin assessments post the falls. (iii). Three of three did not evidence any assessment post the falls for any pain. | (i). – (iii). Ensure all post fall events are managed as per policy and procedure. | PA Moderate | Reporting Complete | |
| The physical environment, internal and external, shall be safe and accessible, minimise risk of harm, and promote safe mobility and independence. | (i). The treatment room requires a handbasin to be fitted. (ii). The outdoor area fences off a lounge/training/activity room are of an insufficient height to prevent a resident climbing over. The fence is beside a water tank, enabling easy access once a resident had climbed over the fence to jump onto the ground. | (i). Ensure there are separate handwashing facilities available in the medication room. (ii). Ensure the fence securing the outdoor area of the PG unit prevents the possibility of residents absconding. | PA Low | Reporting Complete | |
| Service providers shall ensure their health care and support workers have the skills, attitudes, qualifications, experience, and attributes for the services being delivered. | (i). There was no evidence of caregiver training to meet the requirements of the ARHSS contract section D 17.11 (c). (ii). The training schedule for 2023 to 2025 does not demonstrate the following training sessions have been provided to staff: sexuality; falls prevention; skin care; abuse and neglect; food handling; privacy; restraint; and pool safety. | (i). Ensure that caregivers are supported to reach unit standards within set timeframes, as required by section D 17.11 (c) of the ARHSS contract, and that this is recorded in a training log. (ii). Ensure the training schedule demonstrates the following are provided to staff: sexuality; falls prevention; skin care; abuse and neglect; food handling; privacy; restraint; and pool safety. | PA Moderate | Reporting Complete | |
| My services shall be provided in a manner that respects my dignity, privacy, confidentiality, and preferred level of interdependence. | (i). The service uses communal bathing costumes, and robes for when resident use the hydrotherapy pool. (ii). There was evidence of a bowl of communal, unnamed razors, communal hairbrushes and combs, and communal clothing. | (i). Ensure that all residents have their own labelled clothing that is not shared. (ii). Ensure that personal items are not shared. | PA Moderate | Reporting Complete | |
| The following aspects of the system shall be performed and communicated to people by registered health professionals operating within their role and scope of practice: prescribing, dispensing, reconciliation, and review. | Discussion with staff and observation evidenced that transcribing had occurred of resident’s medication. This included the resident’s name, medication and dose. | Ensure policy, procedure and legislative requirements are adhered to by all registered nurses practicing at Manor Park Hospital. | PA Moderate | Reporting Complete | |
| My complaint shall be addressed and resolved in accordance with the Code of Health and Disability Services Consumers’ Rights. | There is no complaints’ register documented. | Ensure there is a process to log and track all complaints in accordance with the Code of Health and Disability Services Consumers’ Rights. | PA Moderate | Reporting Complete | |
| My service provider shall design a Pacific plan in partnership with Pacific communities underpinned by Pacific voices and Pacific models of care. | The Pacific health plan does not reference the Fonofale model care. | Ensure the Pacific health plan references the Fonofale model service and how the service will integrate this into care and support. | 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 | Eight out of eight resident files did not include evidence that residents’ cultural needs, values and beliefs had been considered. | Ensure all residents care plans evidence that their cultural needs, values and beliefs have been considered. | 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. | The provider is yet to develop a system that ensures routine analysis occurs to show entry and decline rates. Specifically, entry and decline rates for Māori. | Ensure a system is implemented that demonstrates that entry and decline rates are routinely analysed and this must include data specifically relating to Māori. | PA Low | 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). Five communal resident toilets and two bathrooms had areas of lino that were overdue for repair and water had penetrated underneath. Maintaining appropriate cleanliness of this area is currently not possible. (ii). The carpet areas within the high care need unit smelt strongly of urine. | (i). Ensure all resident toilets and bathroom areas are maintained on a regular schedule and current areas that need repair, are fixed. (ii). Ensure all carpeted areas are cleaned regularly to minimise/remove the smell of urine in the high care need areas of the facility. | 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. | (i). The service does not include ethnicity with surveillance data. (ii). Infection control data collected does not include identifying organisms. | (i). Ensure that ethnicity is included and analysed with surveillance data. (ii). Ensure that infection control causative organisms are collected and reviewed. | PA Low | Reporting Complete | |
| Service providers shall identify external and internal risks and opportunities, including potential inequities, and develop a plan to respond to them. | (i). The meeting minutes reviewed do not evidence discussion around incident and infection control data. (ii). There is no evidence of resident or family/whānau meetings being held since the previous audit. (iii). Corrective actions identified at internal audits have not been evidenced as being followed up or signed off when completed. (iv). There was no evidence the recent resident/ family/ whānau survey results have been shared with respondents or staff. | (i). Ensure quality data, statistics and their meaning is discussed at meetings. (ii). Ensure there are opportunities for residents and family/whānau to be provided with information and have the opportunity to provide feedback. (iii). Ensure corrective actions for internal audits are signed off when achieved. (iv). Ensure that survey outcomes are followed up and reported back to respondents. | PA Low | Reporting Complete | |
| Service providers shall evaluate progress against quality outcomes. | There is a documented quality plan for each of the years 2023, 2024 and 2025. Each year’s goals are a roll over from the previous year’s plan. There is no documented evaluation of progress towards goals in each of the plans. | Ensure the quality plan is evaluated at regular intervals. | PA Low | Reporting Complete | |
| Service providers shall maintain quality records that comply with the relevant legislation, health information standards, and professional guidelines, including in terms of privacy. | Resident information was on display at the nurse’s station at the front entrance to the facility and was accessible to people with no authorised access. | Ensure resident information is only accessible to people authorised to see it at all times. | PA Low | Reporting Complete | |
| Service providers shall have a clearly defined and documented IP programme that shall be: (a) Developed by those with IP expertise; (b) Approved by the governance body; (c) Linked to the quality improvement programme; and (d) Reviewed and reported on annually. | There is no evidence of annual review of infection control. | Ensure there is a documented annual review of infection control. | 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; Partial Provisional Audit
