Premise details
- Address
- 35 Treadwell Street Springvale Whanganui 4501
- Total beds
- 26
- Service types
- Dementia care
Certification/licence details
- Certification/licence name
- Experion Care NZ Limited - Okere House
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- Experion Care NZ Limited
- Street address
- 283 Kennedy Road Onekawa Napier 4112
- Postal address
- 283 Kennedy Road Pirimai Napier 4112
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 follow the National Adverse Event Reporting Policy for internal and external reporting (where required) to reduce preventable harm by supporting systems learnings. | Three of three resident behaviour incidents which have included altercation (physical and verbal) between two residents did not have separate incident forms completed. | Ensure incidents are documented separately for each resident affected during altercations. | PA Moderate | Reporting Complete | |
| A medication management system shall be implemented appropriate to the scope of the service. | (i)Weekly stock take of controlled drugs was completed three times in a twelve-week period between March and May 2023. (ii)There is no evidence of medication room temperature being monitored and recorded as per policy. | Ensure that stock take of controlled drugs is completed weekly and medication room temperature monitoring completed according to policy. | 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 | (i).Three of three long term care plan evaluations did not demonstrate progress towards meeting the goals. (ii).There was no documented whānau input into the care planning and review process as stated in the communication and care plan policy. | (i). Ensure care plan evaluations evidence progress towards meeting the goals. (ii). Ensure whānau input is documented as evident in care planning and evaluations | PA Low | Reporting Complete | |
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | (i)There was no evidence that internal audits were completed between January to May 2022. (ii) Resident with family whānau support meetings did not occur as documented in the communication policy. (iii) There was no documented evidence that a family/whānau satisfaction survey for 2022 occurred. (iv) The analysis of the satisfaction survey results for April 2023 has not been actioned by the support team. | (i) Ensure internal audits are completed as scheduled to identify improvements to service delivery. (iii)-(iv)Ensure that surveys are completed and analysed as per the quality and risk plan. | 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. | Currently there is no Māori representation at governance level to provide advice and expertise as stated in the business plan scope and review | Ensure there is meaningful Māori representation at governance level to have input to organisational policies. | 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 | (i). Two of five resident care plans do not include a 24-hour reflection of close to normal routine for the resident with detailed interventions to assist staff in strategies for distraction, de-escalation, and management of challenging resident behaviours. (ii). Five of five behaviour care plans do not identify triggers related to behaviours presented by residents. (iii). There are no detailed cultural interventions related to a resident who identifies as Māori. (iv). There are no detailed int | (i). Ensure all resident care plans have a 24-hour reflection of close to normal routine for the residents with detailed interventions to assist staff in strategies for distraction, de-escalation, and management of challenging resident behaviours. (ii). Ensure identified triggers for behaviours are documented for all resident care plans. (iii)-(iv). Ensure interventions are documented to provide sufficient guidance for staff to manage all clinical risks and deliver resident specific care. | 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 | Four of four care plan evaluations did not include detailed review including degree of achievement against the agreed goals and aspirations. | Ensure care plan evaluations are detailed and include the degree of achievement against the agreed goals and aspirations. | PA Moderate | Reporting Complete | |
| Results of surveillance and recommendations to improve performance where necessary shall be identified, documented, and reported back to the governance body and shared with relevant people in a timely manner. | (i). One resident who has had seven urinary tract infections in 2024 did not have corresponding infection reports and short-term care plans completed. (ii). Collated monthly infection reports for the facility do not provide an accurate reflection of the infections that occurred specifically in January, April, June and September 2024. | (i). Ensure that each episode of infection for a resident has corresponding infection report and short-term care plans completed. (ii). Ensure that all infections are documented, and the collated reports provide a true reflection of infections that occur in the facility. | PA Low | Reporting Complete | |
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | (i). There have been no family/whanau meetings held since last audit. (ii). Satisfaction survey results analysis and corrective actions from both staff and resident/relative have not been evidenced as being shared with family/whānau and staff. (iii). There is no evidence of corrective action plan or quality improvement being implemented in relation to the areas that scored low in the survey. | (i). Ensure family/whanau meetings are held as scheduled. (ii). Ensure outcome of satisfaction survey results are communicated to staff and family/whānau. (iii). Ensure corrective actions are identified and implemented for areas of concern from satisfaction survey results. | PA Moderate | Reporting 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 four neurological observations have not been completed as per policy requirements. (ii). Behaviour monitoring charts have not always been completed for two residents who presented with behaviours of concern. | (i)-(ii). Ensure monitoring charts are completed for residents. | 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 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: Provisional Audit
