Premise details
- Address
- Pohlen Hospital 56 Rawhiti Avenue Matamata 3400
- Website
- https://pohlen.co.nz/
- Total beds
- 29
- Service types
- Rest home care, Geriatric, Maternity, Medical
Certification/licence details
- Certification/licence name
- Pohlen Hospital Trust Board - Pohlen Hospital Trust Board
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 24 months
Provider details
- Provider name
- Pohlen Hospital Trust Board
- Street address
- 56 Rawhiti Avenue Matamata 3400
- Postal address
- PO Box 239 Matamata 3440
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 develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | (i)Resident/family whanau, nurses’ meetings and infection control meetings have not been held as scheduled. (ii)Review of the nurses meeting minutes does not demonstrate discussion of all key clinical risk areas. (iii)There is no evidence to demonstrate that the outcome of the satisfaction surveys has been discussed with residents and family/whanau. | (i)Ensure meetings are held as scheduled. (ii)Ensure detailed minutes to evidence key quality and clinical risk areas. (iii)Ensure outcome of satisfaction surveys are discussed with residents/clients and family/whanau | PA Low | In Progress | |
| A medication management system shall be implemented appropriate to the scope of the service. | Controlled medication stocktake was not done weekly as required. | Ensure weekly stocktakes of controlled medications are completed. | 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 | Care plans for rest home and hospital level lacked sufficient detail to guide staff in managing risks and complex health needs in four of four care plans reviewed. Examples included falls prevention strategies, management of PEG feeds, indwelling catheter, pain management, and psychosocial support. | Ensure care plans describe in detail the interventions required to manage complex health needs and mitigate risks. | PA Moderate | In Progress | |
| 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. | There is no evidence that two pressure injuries (one unstageable and one suspected deep tissue injury) have been reported according to the national adverse event reporting policy. | Ensure reporting is completed for pressure injuries in line with the national adverse event reporting policy. | PA Low | In Progress | |
| I shall have the right to make an informed choice and give informed consent. | There was no documented evidence that three residents in double rooms had consented to the sharing arrangement. | Ensure that there is a consent process for sharing of double rooms. | 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 | Neurological observations have not been completed as per the policy for unwitnessed falls or where head injury is suspected in four of four incidents reviewed. | Ensure neurological observations are completed as per policy. | PA Moderate | 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. | Training has been completed as scheduled however there are low numbers of staff who have attended/completed the required training and for the rest home and hospital staff this audit was unable to evidence that staff have received eight hours training. | Ensure that all staff complete the required training as per schedule. | PA Moderate | In Progress | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | There is no evidence of completed performance appraisals in six staff files reviewed. | Ensure that performance reviews are completed as scheduled. | PA Moderate | 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 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: Certification Audit
Audit date:
Audit type: Surveillance Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Surveillance Audit
