Premise details
- Address
- 4 Harbour Road Ohope 3121
- Total beds
- 36
- Service types
- Dementia care, Rest home care
Certification/licence details
- Certification/licence name
- Ohope Beach Care Limited - Ohope Beach Care
- Current auditor
- HealthShare Limited
- End date of current certificate/licence
- Certification period
- 24 months
Provider details
- Provider name
- Ohope Beach Care Limited
- Street address
- Level 4, Parkview Tower 21 Putney Way Manukau Auckland 2104
- Postal address
- PO Box 76142 Manukau Auckland 2241
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 safe and appropriate storage and disposal of waste and infectious or hazardous substances that complies with current legislation and local authority requirements. This shall be reflected in a written policy. | There was no hazardous substance register. A hazardous bleaching/sanitising chemical/agent found in the laundry had been decanted into container previously used for food. The chemical decanting system is inappropriately installed in the only staff room which has prevented them from being able to be in there for periods of time. | Ensure all hazardous substances including chemicals used on site are documented on a hazards register. Ensure all chemicals are stored in suitably and clearly marked containers that accurately describe the contents. Ensure staff have access to a suitable and pleasant area for their work breaks | PA Moderate | 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 acting facility manager is a registered nurse, who is clinically competent and experienced in age care and dementia care but is not experienced in the management of an aged care facility. | Ensure the facility manager is suitably qualified and experienced. | PA High | Reporting Complete | |
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | The previous risk-based approach for identifying and mitigating risk has not been adhered to. This has led to significant gaps in the overall risk management system. | Ensure that an effective risk management system is implemented to identify, monitor and mitigate all potential internal and external risks that threaten safe service delivery and care. | PA High | Reporting Complete | |
| I am informed of the findings of my complaint. | There was no evidence of communication with complainants or that concerns and complaints raised had been resolved. | Ensure that complainants are communicated with and advised of outcomes from complaint investigations. | PA Moderate | Reporting Complete | |
| I shall be provided with the time I need for discussions and decisions to take place. | There was no evidence that residents were being provided with regular and reliable opportunities for discussion or decision making. There has only been one residents meeting held year to date. Actions related to concerns raised had not addressed. | Ensure resident meetings are held regularly, documented and that actions arising are implemented. | PA Low | Reporting Complete | |
| Service providers shall evaluate progress against quality outcomes. | Quality outcomes cannot be evaluated as there were no quality goals, action plans or methods for measuring progress. | Implement methods for evaluating progress against quality outcomes. | PA Moderate | 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. | There was no coherent and readily accessible system for determining how many staff were employed, and what their current qualifications and experience were. This is in breach of the ARCC agreement | Implement a readily accessible system that effectively and accurately reflects the current composition of all staff, along with their skills, experience, qualifications, attitude and attributes. Ensure that all staff working in the dementia unit has achieved unit standards 23920 to 23923 within 18 months of employment. | PA Moderate | Reporting Complete | |
| My complaint shall be addressed and resolved in accordance with the Code of Health and Disability Services Consumers’ Rights. | Management of complaints has not been occurring in accordance with the Code or the organisations policies and procedures. | Ensure the management of complaints adheres to the Code and the organisations policies and procedures. | PA Moderate | Reporting Complete | |
| Governance bodies shall ensure service providers deliver services that improve outcomes and achieve equity for Māori. | There were no systems in place that enabled the director to ensure that service delivery led to improved outcomes and equity for Māori. | That the owner/director establishes methods for monitoring and ensuring services are delivered in ways that improve health outcomes and achieve equity for Māori. | PA Low | Reporting Complete | |
| Governance bodies shall ensure service providers identify and work to address barriers to equitable service delivery. | There were no systems or methods for identifying and eliminating barriers to equitable service delivery. | Establish methods for identifying and addressing barrier to equitable service delivery. | PA Low | Reporting Complete | |
| There shall be a clinical governance structure in place that is appropriate to the size and complexity of the service provision. | There is no clinical governance structure or shared responsibility and accountability for the culture of engagement in resident safety and continuous quality improvement. | Implement suitable and appropriate methods for management, registered nurses and other staff to work together to improve and be held accountable for the quality and safety of the services they provide. | PA Moderate | Reporting Complete | |
| Health care and support workers shall have the opportunity to be involved in a debrief and discussion, and receive support following incidents to ensure wellbeing. | Policies and procedures for determining staff health and wellbeing were not being implemented. The support provided to staff following stressful incidents, such as the sudden death of a visitor recently, was informal. | Ensure all staff have the opportunity to debrief following stress incidents and implement systems for determining staff health and wellbeing. | PA Low | Reporting Complete | |
| Support systems promote health care and support worker wellbeing and a positive work environment. | There has been an overall lack of support or implementation of coherent systems which promote staff wellbeing or positivity in the workplace. | Implement processes which promote staff wellbeing and a positive work environment. | PA Moderate | Reporting Complete | |
| Information held about health care and support workers shall be accurate, relevant, secure, and confidential. Ethnicity data shall be collected, recorded, and used in accordance with Health Information Standards Organisation (HISO) requirements. | The ethnicity of staff had not identified, collected or recorded as required. | Ensure that information held about staff is accurate and includes all the required information. | PA Low | Reporting Complete | |
| Governance bodies shall have meaningful Māori representation on relevant organisational boards, and these representatives shall have substantive input into organisational operational policies. | There were no evidence of Māori representation and input to service delivery or operational practices. | Implement a method for demonstrating engagement with suitable Māori representatives who have regular input and oversight of cultural procedures. | PA Low | Reporting Complete | |
| Service providers shall improve health equity through critical analysis of organisational practices. | There are no systems identified or established for measuring and improving health equity within the service. | Determine methods for analysing and measuring improvements in health equity. | 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. | Surveillance data does not include ethnicity. | Add ethnicity to infection surveillance data. | 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 | InterRAI reviews and resultant referrals to the NASC in response to a change in health care needs were not always completed in a timely manner. | Ensure referrals to the NASC for a review of health care needs occurs as soon as practicable, | PA High | Reporting Complete | |
| Professional qualifications shall be validated prior to employment, including evidence of registration and scope of practice for health care and support workers. | Evidence of staff and allied health professionals’ registration and scope of practice was not recorded. | Maintain up to date records of regulated staff and health professionals who | 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. | New staff were not being adequately orientated and inducted at the start of their employment. | Ensure all new staff complete orientation and are inducted in ways that ensure they understand their roles, obligations and responsibilities and the essential components of service delivery. | PA Moderate | Reporting Complete | |
| There shall be a documented pathway for IP and AMS issues to be reported to the governance body at defined intervals, which includes escalation of significant incidents. | Infection control and antimicrobial surveillance (AMS) issues including significant infection incidents were not being reliably reported up to the director. | Ensure infection control and AMS issues and other significant IP information is reported to the director/owner at regular intervals. | PA Low | 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. | Staff educational achievements were not being accurately recorded. There was no reliably coordinated or integrated system for identifying, planning, delivering and recording staff training and education. | Implement a planned and coordinated system for identifying, planning, delivering and recording staff learning and development. | PA Moderate | Reporting Complete | |
| Governance bodies shall ensure service providers deliver services that improve outcomes and achieve equity for tāngata whaikaha people with disabilities. | There were no systems in place that enabled the owner/director to ensure that service delivery led to improved outcomes and equity for tāngata whaikaha people with disabilities. | That the owner/director establish methods for monitoring and ensuring services are delivered in ways that improve health outcomes and achieve equity for tāngata whaikaha. | PA Low | 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. | Incident and accident data is being collated but is not yet being used to support systems learning. | Continue to develop systems for analysing all reported incidents and accidents and use the data to facilitate staff and system wide learning. | 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 activities program does not consistently enhance and develop each resident’s skills, strengths and interests. | Ensure that all residents are consistently provided opportunities to engage in meaningful activities that enhance and develop their interests, strengths and skills. | 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. | The electronic staff records system did not contain all the information necessary to ascertain staff competencies. | Implement an effective system for determining and developing staff competencies. | PA Moderate | 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 | Early warning signs of deterioration or development of conditions that impact a resident’s wellbeing were not always documented or escalated. | Ensure early warning signs are reported, documented and escalated appropriately. | PA High | Reporting Complete | |
| There shall be clearly documented processes for determining a person’s entry into a service. | The admission process was not implemented consistently. | Ensure that the service clinical leaders are involved in all decision making about potential residents’ entry to the service. | PA Moderate | Reporting Complete | |
| Service providers shall develop and implement policies and procedures in accordance with good employment practice and meet the requirements of legislation. | None of the eight staff records sampled contained all the information required to confirm good employment practice and adherence to New Zealand employment legislation. | Ensure that evidence of recruitment (interviews, reference checks) qualifications, job descriptions, and that the entire signed employment agreements held for each staff member. | PA Moderate | 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. | New residents were not being seen by the GP with five working days of admission.Not all interRAI assessments and long-term care plans had been completed within 21 days of admission as required in clause D16.2 of the Age-Related Residential Care (ARRC) service agreement. | Ensure new residents are seen by the GP and that interRAI assessments and care plans are completed within the required timeframe. | 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. | Four of the eight staff records sampled did not have job descriptions attached. One staff member who had been employed as an IT manager for 18 months did not have a job description and their role or position had not been clarified verbally or in writing. Three of the eight staff files sampled did not have job descriptions attached. One staff member who had been employed as an IT manager had never had their position clarified. | Ensure all staff employed have position descriptions, and that they understand their roles, functions, accountabilities and responsibilities. | PA Moderate | Reporting Complete | |
| Governance bodies shall have demonstrated expertise in Te Tiriti, health equity, and cultural safety as core competencies. | The owner has not undertaken any learnings related to Te Tiriti o Waitangi, heath equity or cultural safety. | That the director undertakes learning and develop understanding and expertise in Te Tiriti o Waitangi, health equity and cultural safety. | PA Low | Reporting Complete | |
| Service providers shall assist with training and support for people and service providers to maximise people and whānau receiving services participation in the service. | It was uncertain that staff had attended training or been informed about how to maximise residents and whānau participation in the service. | Ensure that staff are provided with training on how to support residents and whānau participation in the service. | 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. | The process for identifying risks and opportunities was limited in its scope, did not identify potential inequities and has not been acted on. | Identify all external and internal risks and opportunities, including potential health and service delivery inequities, and develop a plan that responds to them. | PA Moderate | Reporting Complete | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | There was no evidence of annual performance appraisals or 90-day post-employment reviews occurring. | Ensure all staff members are given an opportunity to discuss and review their performance according to the intervals described in policy. | PA Moderate | Reporting Complete | |
| Service providers shall establish environments that encourage collecting and sharing of high-quality Māori health information. | There were no methods or systems in place for identifying, collecting and sharing evidence based and current Māori health information. | Encourage the collecting and sharing of high-quality Māori health information. | 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. | The 2023 business goals were not being monitored, reviewed and evaluated for progress. | Implement specific, measurable, relevant and appropriate business goals and ensure these are monitored, reviewed and evaluated regularly. | PA Low | 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. | There has been an improvement in the number of HCA’s working in the dementia wing who have dementia specific training, however, there remains some staff who are still required to complete the NZQA dementia unit standards. | All staff who work in the dementia area are required to have the approved NZQA training. | PA Low | In Progress | |
| Governance bodies shall have demonstrated expertise in Te Tiriti, health equity, and cultural safety as core competencies. | The owner/director has not undertaken sufficient learnings related to Te Tiriti o Waitangi, health equity and cultural safety. | The owner is required to complete sufficient learnings related to Te Tiriti o Waitangi, health equity and cultural safety. | PA Low | 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. | Improvements have been made in recording staff educational achievements, however the system for delivering planned education requires further implementation. | Implement planned regular education for staff. | PA Low | In Progress | |
| I shall be provided with the time I need for discussions and decisions to take place. | Processes for resident/whānau feedback, for example verbal concerns, feedback from resident meetings, and satisfaction surveys do not ensure information is collated, investigated and reported on. | Collate feedback from residents/whanau in a manner that identifies potential trends and makes timely improvements. | PA Low | In Progress | |
| Information held about health care and support workers shall be accurate, relevant, secure, and confidential. Ethnicity data shall be collected, recorded, and used in accordance with Health Information Standards Organisation (HISO) requirements. | The ethnicity of staff has not been identified, collected or recorded. | Document staff ethnicity. | PA Low | In Progress | |
| Service providers shall invest in the development of organisational and health care and support worker health equity expertise. | Staff have not received training specific to equity. | Provide staff training related to equity. | PA Moderate | In Progress | |
| 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. | De-escalation training is not being consistently provided. | Provide de-escalation training consistently. | PA Moderate | In Progress | |
| 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. | Infection prevention education has not been provided at defined intervals by a person with infection prevention expertise. | Provide infection prevention education at defined intervals by a person with infection prevention education. | PA Low | In Progress | |
| A process shall be implemented to identify, record, and communicate people’s medicinerelated allergies or sensitivities and respond appropriately to adverse events. | Not all medication files had the residents’ medication allergies and sensitivities documented. | Ensure all residents medication allergies and/or sensitivities are documented on the medication file. | PA Moderate | Reporting Complete | |
| Service providers ensure competent health care and support workers manage medication including: receiving, storage, administration, monitoring, safe disposal, or returning to pharmacy. | The effectiveness of PRN medications administered was not consistently documented. | Ensure the effectiveness of PRN medications are consistently documented. | 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. | Not all staff in the dementia unit had the skills, and experience to competently manage resident acuity. | Ensure there are enough skilled and experienced staff on site to provide clinically safe services. | PA Moderate | Reporting Complete | |
| Service providers shall invest in the development of organisational and health care and support worker health equity expertise. | Some training related to health equity occurred in July 2023 but there was no recorded description of the content. Staff interviewed were not able to articulate what was meant by health equity. There was no recorded description about the content of the health equity education provided in July 2023, or any process for assessing staff understanding or expertise. | Ensure that all staff understand the principles and practices of health equity. | 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
