Premise details
- Address
- 10 Milton Road Orewa 0931
- Total beds
- 36
- Service types
- Dementia care, Rest home care
Certification/licence details
- Certification/licence name
- Agape Care Limited - Milton Court Rest Home
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- Agape Care Limited
- Street address
- 10 Milton Road Orewa 0931
- 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 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 was no evidence of an annually reviewed infection control programme. The programme was last reviewed in March 2020. | Ensure the infection control programme is annually reviewed as required by the organisation’s policy. | 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). The caregivers have completed three of the four required unit standards to meet the requirements of the ARC contract E4.5.1. ii). The activities coordinator has not had training around providing specialised activities for residents in the dementia unit. iii). The RN has not completed specialist infection prevention control training to enable her to complete her role as infection prevention control coordinator. | i). Ensure specialist training requirements for care givers in the dementia unit to meet the ARC contract E4.5.1 are met. ii). Ensure the activities coordinator completes training around providing specialised training for residents in the dementia unit. iii). Provide training to the RN/infection prevention and control coordinator to assist in meeting the requirements of the role. | PA Low | In Progress | |
| 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 was no evidence the business plan had been reviewed for 2022. | Ensure the annual review of the business plan is completed. | 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. | Eight corrective action plans were not signed off by the owner/manager or their delegate. | Ensure corrective action plans are signed off by the owner/manager or their delegate, | PA Low | Reporting Complete | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | In reviewing the files three of the four files did not have an appraisal completed within the timelines required by the policy. | Ensure appraisals are completed within the timeframes required. | PA Low | Reporting Complete | |
| Service providers shall evaluate progress against quality outcomes. | Quality data is collected; however this was not reviewed in 2022 to demonstrate progress quality outcome’s. | Collate the clinical data to inform ongoing quality planning and service delivery. | 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). Two of the four files reviewed that required initial interRAI assessments evidenced these were not completed within the required timeframes. ii). Three of the four files reviewed did not have interRAI reassessments completed within the required timeframes. iii). Long term care plans were not evidenced as being routinely reviewed in three of four long term care plans sampled. | i).- ii). Ensure interRAI assessments and reassessments are completed within the required timeframes. iii). Ensure all long term care plans are reviewed at least six monthly. | 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). Two residents (one rest home and one dementia level resident) care plans were not evidenced as evaluated at least six-monthly. ii). Where evaluations had been completed, these did not reflect the residents progression towards meeting goals. | i). & ii). Ensure that care plan evaluations are completed in a timely manner, and they reflect progress on resident goals. | 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 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: Surveillance Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Surveillance Audit
