Premise details
- Address
- 4 Harbour Road Ohope 3121
- Website
- https://www.eldernet.co.nz/Facilities/Rest_Home_Care/Ohope_Beach_Care_Ltd/Service/DisplayService/FaStID/700
- Total beds
- 36
- Service types
- Dementia care, Rest home care
Certification/licence details
- Certification/licence name
- Ohope Healthcare Limited - Ohope Beach Care
- Current auditor
- Quality Health
- End date of current certificate/licence
- Certification period
- 12 months
Provider details
- Provider name
- Ohope Healthcare Limited
- Street address
- 4 Harbour Road Ohope 3121
- Postal address
- PO Box 26718 Epsom Auckland 1344
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 |
|---|---|---|---|---|---|
| The physical environment, internal and external, shall be safe and accessible, minimise risk of harm, and promote safe mobility and independence. | There are two environmental areas which require attention. Firstly, the garden areas in the secure dementia care area need to be made secure, and secondly, the laundry area requires refurbishment with easy availability for PPE. | Provide evidence that security issues in the secure dementia care garden areas have been addressed and that refurbishment of the laundry has taken place and facilitates easy access to PPE. | 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. | Not all staff on four weeks of rosters had first aid certification. | Provide evidence that first aid certified staff are rostered 24/7. | PA Low | Reporting Complete | |
| Service providers shall develop and implement policies and procedures in accordance with good employment practice and meet the requirements of legislation. | In the files sighted, no staff had reference checking completed as per policy. | Provide evidence that all staff entering the service have been reference checked. | 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. | Not all staff had a job description in place for their role(s) in the files sighted. | Provide evidence that all staff have a job description in place for all of their roles in the service. | PA Moderate | Reporting Complete | |
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | Neurological observations are not being completed following unwitnessed falls or a witnessed ‘blow’ to the head, as required by the service’s policy and in alignment with best practice guidelines. In addition, the internal audit schedule is not being consistently implemented, and internal audits have not been accurately completed with corrective actions identified and addressed. | Provide evidence that neurological observations are being fully completed following an unwitnessed fall or a witnessed ‘blow’ to the head in accordance with the prescribed timeframes outlined in the service’s policy and best practice standards. Provide evidence that the annual internal audit schedule has been fully implemented and that internal audits have been accurately completed, with all sections filled in, deficits clearly identified, and corrective actions developed and implemented. | PA Moderate | In Progress | |
| There shall be adequate personal space that is safe and age appropriate, and has accessible areas to meet relaxation, activity, lounge, and dining needs. | There is an insufficient amount of soft furniture in the lounge/dining area of the secure dementia area to promote the comfort of residents during leisure and recreation activities. | Provide evidence that the lounge/dining area of the secure dementia care area has been reconfigured/refurbished to provide comfortable seating for the residents. | PA Low | Reporting Complete | |
| Health care and support workers shall be trained in least restrictive practice, safe practice, the use of restraint, alternative cultural-specific interventions, and de-escalation techniques within a culture of continuous learning. | Staff have not been trained in the least restrictive practice, safe restraint practice, alternative cultural-specific interventions, and de-escalation techniques in 2024 or 2025. | Provide evidence that staff have been trained in the least restrictive practice, safe restraint practice, alternative cultural-specific interventions, and de-escalation techniques. | PA Moderate | Reporting Complete | |
| Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services. | Contracting of staff members to move from the current to the prospective new provider has not yet occurred. Not all staff who work in the secure dementia care unit of the facility have completed or been enrolled in the required NZQA programme for the service in the appropriate timeframes. | Provide evidence that sufficient staff have been contracted by the prospective owner of the service on a permanent employment basis to meet the clinical and cultural needs of the resident population. Provide evidence that there are sufficient staff qualified in the NZQA programme to meet the needs of residents in the secure dementia care area of the facility. | PA Moderate | Reporting 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. | There is no formal education plan in place to meet the requirements of the Ngā Paerewa Standard and the facility’s contracts with Te Whatu Ora. A system for delivering and recording a relevant education programme for staff requires implementation. | Provide evidence of a formal education plan to meet the requirements of the Ngā Paerewa Standard and the requirements of the facility’s contracts with Te Whatu Ora. Provide evidence that the system for delivering and recording of relevant education for staff has been implemented. | PA Moderate | Reporting Complete | |
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | Neurological observations are not being conducted following an unwitnessed fall or a witnessed ‘blow’ to the head, as required by the service’s policy and in accordance with best practice guidelines. Additionally, the internal audit schedule has not been consistently followed. | Provide evidence that neurological observations are being completed following an unwitnessed fall or a witnessed ‘blow’ to the head and that staff training records show that staff have been educated in the completion of neurological observations. Provide evidence that the annual internal audit schedule has been followed through the provision of complete internal audits to match the internal audit schedule. | PA Moderate | Reporting Complete | |
| Service providers shall understand and comply with statutory and regulatory obligations in relation to essential notification reporting. | The FM of the facility does not fully understand or comply with statutory and regulatory obligations in relation to essential notification reporting. | Provide evidence that the FM has sought information and/or education to fully understand and comply with statutory and regulatory obligations in relation to essential notification reporting. | PA Moderate | Reporting Complete | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | Performance appraisals for staff are not being conducted annually. | Provide evidence that all staff have had a performance appraisal conducted annually. | PA Moderate | Reporting Complete | |
| Service providers shall implement systems to determine and develop the competencies of health care and support workers to meet the needs of people equitably. | Not all staff have completed all the annual competencies required and there is no process currently in use to record completion of competency for staff. | Provide evidence that a process has been implemented to record competency completion for all staff and that all staff have completed the competencies required annually. | PA Moderate | Reporting Complete | |
| 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 residents in the secure dementia care unit had no 24-hour care plan in place that addressed the residents’ previous lifestyle patterns and routines, to enable the residents’ previous lifestyle patterns to be maintained. | Provide evidence that the residents in the secure dementia care unit have a 24-hour care plan in place that addresses the residents’ previous lifestyle patterns and routines. | PA Low | Reporting Complete | |
| Services shall ensure health care and support workers receive Te Tiriti o Waitangi training and that this is reflected in day-to-day service delivery. | Staff had not participated in training on Te Tiriti o Waitangi in the past two years. | Provide evidence that staff have participated in training on Te Tiriti o Waitangi. | PA Low | Reporting Complete | |
| Alternative essential energy and utility sources shall be available, in the event of the main supplies failing. | Emergency supplies are not being checked on a regular basis, and the current water storage is insufficient to meet the recommended regional guidelines. | Provide evidence that a formal regime has been put in place to regularly check emergency supplies and that the availability of water in storage is sufficient to meet the recommended regional guidelines. | PA Moderate | 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. | The IP and AMS programme has not been reviewed annually. | Provide evidence that the IP and AMS programme has been reviewed, and that there is a process in place to ensure the programme is reviewed annually. | PA Low | Reporting Complete | |
| Infection prevention education shall be provided to health care and support workers and people receiving services by a person with expertise in IP. The education shall be: (a) Included in health care and support worker orientation, with updates at defined intervals; (b) Relevant to the service being provided. | IP and AMS education had not been completed in 2024 or 2025 by a person with expertise in IP. | Provide evidence that IP and AMS education has been completed by a person with expertise in IP, and that IP and AMS education is included in the facility’s education plan. | PA Moderate | Reporting Complete | |
| A person with IP expertise shall be involved in procurement processes for equipment, devices, and consumables used in the delivery of health care. | There are no staff at Ōhope who have expertise in IP or AMS to support decision-making related to procurement. | Provide evidence there is a staff member with IP and AMS expertise advising on procurement processes. | PA Moderate | Reporting Complete | |
| There is an IP role, or IP personnel, as is appropriate for the size and the setting of the service provider, who shall: (a) Be responsible for overseeing and coordinating implementation of the IP programme; (b) Have clearly defined responsibility for IP decision making; (c) Have documented reporting lines to the governance body or senior management; (d) Follow a documented mechanism for accessing appropriate multidisciplinary IP expertise and advice when needed; (e) Receive continuing education | There is currently no job description in place for the ICN position at Ōhope. Additionally, the current incumbent has not undertaken recent training in IC and AMS, which is necessary to competently oversee the IP and AMS programmes. | Provide evidence that the ICN at Ōhope has a job description for the role and has had recent training in IC and AMS so that they can competently oversee the IP and AMS programmes. | PA Moderate | Reporting Complete | |
| Service providers shall ensure there are safe and effective laundry services appropriate to the size and scope of the health and disability service that include: (a) Methods, frequency, and materials used for laundry processes; (b) Laundry processes being monitored for effectiveness; (c) A clear separation between handling and storage of clean and dirty laundry; (d) Access to designated areas for the safe and hygienic storage of laundry equipment and chemicals. This shall be reflected in a writt | Appropriate PPE is not being used by laundry staff when loading the washing machine with soiled clothing. | Provide evidence that laundry staff have received education in appropriate PPE use when loading washing machines with soiled clothing. | PA Moderate | Reporting Complete | |
| There shall be an executive leader who is responsible for ensuring the commitment to restraint minimisation and elimination is implemented and maintained. | There is no job description in place to guide the practice of the RN working as the restraint coordinator and no education specific to the role has been undertaken. | Provide evidence that there is a job description in place to guide the practice of the RN working as the restraint coordinator and that education specific to the role has been undertaken. | PA Moderate | Reporting Complete | |
| Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services. | The shortage of RN hours is impacting completion of core clinical and safety tasks, creating a risk to resident safety and care continuity. | Provide evidence that there are sufficient RN hours available to the facility to provide clinically safe services. | PA Moderate | In Progress | |
| There shall be adequate personal space that is safe and age appropriate, and has accessible areas to meet relaxation, activity, lounge, and dining needs. | There is an insufficient amount of soft furniture in the lounge/dining area of the secure dementia area to promote the comfort, wellbeing, and dignity of residents. Staff are not utilising other options available to them to support the comfort of residents. | Provide evidence that the lounge/dining area in the secure dementia care unit has been reconfigured or refurbished to ensure adequate, comfortable seating for all residents. The refurbishment or reconfiguration should promote resident wellbeing, comfort, and dignity, and allow ease of movement within the space. | PA Moderate | In Progress | |
| 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. | Care plans to guide the support required by residents were not consistently completed in a timely manner. | Provide evidence that all residents have an initial care plan completed in a timely manner following admission. | PA Moderate | In Progress | |
| 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. | The IP and AMS programme has not been reviewed annually. | Provide evidence that the IP and AMS programme has been reviewed, and that there is a process in place to ensure that the programme is reviewed annually | PA Low | 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 | The documentation identifying the care the resident required was not consistent with the resident’s needs. | Provide evidence that the documentation identifying the care the resident requires is consistent with the resident’s needs. | PA Moderate | In Progress | |
| Services shall ensure health care and support workers receive Te Tiriti o Waitangi training and that this is reflected in day-to-day service delivery. | Staff at Ōhope had not received any training on Te Tiriti o Waitangi. | Provide evidence that staff at Ōhope receive training on Te Tiriti o Waitangi. | PA Moderate | In Progress | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | The absence of a performance review process limits the organisation’s ability to monitor staff competence and support professional development, which may impact the quality and consistency of service delivery. | Provide evidence that a formal performance review process has been developed and implemented to ensure all staff receive regular, documented performance appraisals in accordance with policy and contractual requirements. The process should include clear timeframes, defined responsibilities, and documentation of performance goals, competency review, and professional development plans. Provide evidence that appraisals have been completed for all staff who are due or overdue. | PA Moderate | In Progress | |
| Alternative essential energy and utility sources shall be available, in the event of the main supplies failing. | There is no established process to regularly check civil defence medical, safety, food, and water supplies to ensure they are complete, in working order, and within use-by dates. Current emergency provisions are insufficient, with stored food limited to what would be available in the kitchen on the day, a few muesli bars, and approximately 400 litres of water, which does not meet regional guidelines and does not account for staff who may be present during a civil defence emergency. This indicate | Provide evidence that a formal regime has been put in place to regularly check emergency supplies, including food, and that the availability of water in storage is sufficient to meet the recommended regional guidelines. | PA Moderate | In Progress | |
| Service providers shall understand and comply with statutory and regulatory obligations in relation to essential notification reporting. | There was insufficient implementation of statutory and regulatory reporting processes. While the FM and AFM were able to describe reporting obligations, the facility has not consistently submitted required notifications. Additionally, the facility does not have access to the HQSC adverse events portal, which limits the ability to report incidents in a timely manner. | Provide evidence that the service has processes in place to ensure that statutory and regulatory reporting obligations are fully implemented and consistently applied. Specifically, the service must provide evidence that all required notifications to HealthCERT and the HQSC have been completed in accordance with statutory requirements, that it has ensured access to the HQSC adverse events portal, and that it maintains documentation of all notifications and evidence of timely reporting in line wit | PA Moderate | 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 | The residents were not being reviewed by the GP within the required timeframes. | Provide evidence of documentation in the residents’ files that residents are being reviewed every month, or every three months if deemed medically stable by the GP. | 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. | Climbable structures in the larger rear garden and potentially breachable fencing and gates at the front of the secure dementia care unit create a risk of residents leaving the secure areas unsupervised. Residents are unable to access the rear gardens independently. | Provide evidence that all outdoor areas are safe and secure for resident use. This includes removing or modifying climbable structures in the larger rear garden to prevent residents from accessing unsafe areas, strengthening fencing and gates at the front exit from the secure dementia care unit to prevent residents from breaching the boundary, and reviewing and updating procedures for staff supervision of residents in outdoor areas to ensure safe independent access to garden areas. | PA Moderate | Reporting Complete | |
| Service providers shall evaluate progress against quality outcomes. | There was no evidence available within the facility to show that quality data had been analysed, trended, and regularly reviewed, or that outcomes are clearly communicated to staff. | Provide evidence to show that quality indicators are routinely analysed and trended over time, results are shared through staff/quality meetings, with minutes demonstrating discussion and follow-up, and that visual representations (eg, graphs or dashboards) are available and updated to support staff understanding. | PA Moderate | Reporting Complete | |
| Professional qualifications shall be validated prior to employment, including evidence of registration and scope of practice for health care and support workers. | A process is not in place to ensure that all health professionals involved in the service, including GPs, pharmacists, and any contracted clinicians, have their APCs verified annually. | Provide evidence that a process is implemented to ensure that all health professionals/clinicians involved in the service have their APCs verified annually | PA Moderate | Reporting Complete | |
| Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided. | The absence of core orientation content during the orientation process may compromise staff understanding of legal, ethical, and cultural responsibilities, increasing the potential for inconsistent or unsafe service delivery. | Develop and implement a comprehensive orientation programme that includes all required service components relevant to staff roles. This must include training on the Code, informed consent, EPOA, Te Tiriti o Waitangi, and other cultural considerations. | PA Moderate | Reporting Complete | |
| 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. | Adverse and near-miss events were not being consistently documented in accordance with the National Adverse Events Reporting Policy. Whānau interviews confirmed they were not always informed of adverse events affecting residents. | Provide evidence to show that staff have received education on adverse event reporting and communication. Provide evidence to show that adverse event forms are being fully completed, including all required signatures and RN review, and provide evidence of whānau communication for all adverse events. | 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: Surveillance Audit
Audit date:
Audit type: Provisional Audit
