Premise details
- Address
- 365 Marine Parade New Brighton Christchurch 8061
- Total beds
- 34
- Service types
- Rest home care
Certification/licence details
- Certification/licence name
- Pacific Haven (2015) Limited - Pacific Haven Residential Care
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- Pacific Haven Residential Care (2015) Limited
- Street address
- 365 Marine Parade New Brighton Christchurch 8061
- Postal address
- 365 Marine Parade New Brighton Christchurch 8061
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 |
|---|---|---|---|---|---|
| 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 six resident files reviewed, evidenced inconsistent entries in the progress notes by the registered nurse | Ensure resident records include regular registered nurse input/assessment and evaluation. | PA Moderate | Reporting Complete | |
| Each person’s room shall have at least one external window, providing natural light, and appropriate ventilation and heating. | i). Toilet and shower areas has damaged walls and requires repair and refurbishment. ii). Walls are not able to be cleaned properly posing a potential infection control risk. iii). Staff interviewed confirmed there is poor ventilation in the shower room. | i). – ii). Ensure the walls in the shower and toilet areas are repaired and repainted, and easy to clean. iii). Ensure the ventilation system in shower areas is improved. | PA Low | Reporting Complete | |
| My service provider shall communicate with other agencies involved in my care. | Six of eleven accident/incident forms failed to indicate family are kept informed following an adverse event. | Ensure that there is documented evidence to confirm open disclosure with applicable parties following an adverse event. | PA Low | Reporting Complete | |
| Governance bodies shall evidence leadership and commitment to the quality and risk management system. | There is a lack of documented evidence to support ongoing review of quality goals by governance and the management team. | Ensure there is documentation to support governance review of quality goals. | PA Low | In Progress | |
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | i). Staff meetings, quality meetings and resident, family meetings have not been documented as occurring throughout 2023. ii). Internal audits scheduled for 2023 were not evidenced as occurring as per schedule. Most audits are scheduled two to four times per annum; however, the completed schedule evidences the majority were completed once only. The completed audits included (but not limited to): admission audit; progress notes; care plan and resident file; cultural safety and spiritual beliefs; | i)-(iii). Ensure internal audits are fully implemented and documentation reflects implementation of corrective action plans. | PA Moderate | In Progress | |
| 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). One resident with recent changes in mobility, and an increase in pain did not have interventions and associated risks documented. ii). Two residents assessed with behavioural requirements risk did not have interventions documented to manage the risk. iii). One resident with seizures had an action plan in a paper-based file; however, there was no reference or management strategies documented in the care plan. iv). One resident with a history of cardiac risks did not have associated risks or i | (i). – (vi). Ensure care plans have detailed interventions documented to provide guidance to staff on care management and are updated to reflect changes to resident needs and management plan. | PA Moderate | In Progress | |
| A medication management system shall be implemented appropriate to the scope of the service. | i). Three eye drops not labelled with an opening date, were in current use. ii). Clonazepam has been dispensed into a container by staff but does not evidence an opening date. iii). Effectiveness of ‘as required’ medication is not recorded in the medication system or in progress notes. | i-ii.) Ensure eye drops are stored and discarded as per manufacturer’s instructions. iii). Ensure effectiveness of ‘as required’ medication is documented. | PA Moderate | In Progress | |
| Service providers shall identify external and internal risks and opportunities, including potential inequities, and develop a plan to respond to them. | i). Annual resident and family/whānau satisfaction surveys have been correlated but not yet analysed or an action plan developed. ii). Identification of risks or opportunities to prevent future events are not always documented on incident forms. iii) Clinical data analysis is not shared with staff, as confirmed on interview with caregivers. | i). Ensure annual satisfaction survey results are reviewed by management, opportunities for improvement are identified and a plan to respond is identified. ii). Ensure incident forms identify risks and opportunities to prevent future events. iii). Ensure clinical data analysis is shared with staff. | 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. | i). There is no evidence of a documented annual education and training schedule for 2023 or 2024. ii). There was minimal evidence of training being provided since August 2022 and all of 2023. There has been no documented training for mandatory subjects including (but not limited to): advocacy; Code of Rights; privacy; informed consent; complaints; abuse and neglect; falls prevention; infection control; challenging behaviour; pressure injury prevention; cultural training; medication; and continen | i). –ii). Ensure an education planner is documented and implemented and includes all mandatory training. iii). Ensure the infection control coordinator completes external education. | 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 infection control programme has not been evidenced as reviewed and reported on annually. | Ensure the infection control programme is reviewed and reported on 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 | i). Wound assessments and a management plan were not documented for one current resident with a complex wound. ii) A wound register has not been maintained, with evidence of wounds no longer being treated on the register for several months. | i). Ensure all wounds are documented on the wound register. ii). Ensure the wound register reflects current wounds. | PA Moderate | 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 | i). Three of five long-term care plan evaluations had not been completed six-monthly. ii). Three short-term care plan evaluations did not evidence evaluation since commencement between two and five months previously. iii). The care plan evaluations of five of five files reviewed did not document progress towards the goals. | i)-ii). Ensure care plans evaluations occur as per policy and legislative requirement. iii). Ensure care plan evaluations reflect progress towards the goals. | PA Moderate | In Progress | |
| A process shall be implemented to identify, record, and communicate people’s medicinerelated allergies or sensitivities and respond appropriately to adverse events. | One paper-based medication chart did not have photo identification and allergies documented. | Ensure paper-based medication charts include photo identification, and allergies are documented. | PA Moderate | In Progress | |
| Surveillance methods, tools, documentation, analysis, and assignment of responsibilities shall be described and documented using standardised surveillance definitions. Surveillance includes ethnicity data. | i). Infection surveillance data is not monitored and analysed for trends, monthly and annually. ii). Pacific Haven Village does not yet incorporate ethnicity data into surveillance methods. | i). Ensure infection surveillance data is monitored and analysed for monthly and annual trends. ii). Ensure ethnicity data is incorporated into surveillance reporting. | PA Low | In Progress | |
| I shall give informed consent in accordance with the Code of Health and Disability Services Consumers’ Rights and operating policies. | Two of five files did not evidence signed consent forms. | Ensure all residents have signed consent forms on file. | PA Low | In Progress | |
| 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. | There is no documented evidence of formal infection surveillance reporting to the owners. | Ensure there is documented evidence of infection surveillance reporting to the owners. | PA Low | In Progress |
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
