Premise details
- Address
- 348 High Street Dannevirke 4930
- Total beds
- 49
- Service types
- Geriatric, Medical, Dementia care, Rest home care
Certification/licence details
- Certification/licence name
- Rahiri Lifecare Limited - Rahiri
- Current auditor
- The DAA Group Limited
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- Rahiri Lifecare Limited
- Street address
- Level 5 25 Broadway Newmarket Auckland 1023
- Postal address
- PO Box 56114 Dominion Road Auckland 1446
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 |
|---|---|---|---|---|---|
| A medication management system shall be implemented appropriate to the scope of the service. | A process was not in place to ensure a six-monthly qualitative auditing of controlled drugs by the contracted pharmacist. No qualitative audit had been undertaken within the last six months. | Implement a system to ensure that the six-monthly checks by the pharmacist occur as required by legislation. | PA Low | Reporting Complete | |
| The nutritional value of menus shall be reviewed by appropriately qualified personnel such as dietitians. | There was no evidence to verify that the menu had been reviewed by appropriately qualified personnel, such as a dietitian, within a two-year timeframe. The organisation was having the menu reviewed by a dietitian, but their response had not been received by the days of the audit. | Provide evidence that the menu has been reviewed by an appropriate person, such as a dietitian, within the last two years. | 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. | There is a document which provides guidelines for developing a risk management plan for the facility, but this had not been prepared. This is new process for the CHM with the new owners. Potential inequities in the delivery of care and the impact of additional dementia beds have not been identified as a risk. | Prepare a risk management plan for Rahiri using the organisation’s guidelines and ensure that relevant risks are monitored. | PA Low | Reporting Complete | |
| Service providers shall maintain an information management system that: (a) Ensures the captured data is collected and stored through a centralised system to reduce multiple copies or versions, inconsistencies, and duplication; (b) Makes the information manageable; (c) Ensures the information is accessible for all those who need it; (d) Complies with relevant legislation; (e) Integrates an individual’s health and support records. | Rahiri transitioned from paper-based clinical file management to an electronic management system in November 2023. Due to this timeframe, not all data had been fully collected and stored electronically at audit. Elements of a resident’s clinical file were stored electronically as well as other paper-based file locations. There is not one, integrated clinical record. | Ensure the captured data is collected and stored through a centralised system and all resident health information can be accessed in one location. | PA Low | Reporting Complete | |
| Service providers shall improve health equity through critical analysis of organisational practices. | During the audit there was no evidence of staff members having opportunities to analyse organisational practices to assist in improving health equity at Rahiri (see also 2.1.7). | Ensure there is a process for service providers to follow to analyse organisational practices to assist in improving health equity. | PA Low | Reporting Complete | |
| Governance bodies shall ensure service providers identify and work to address barriers to equitable service delivery. | This process was new, and not yet ‘embedded’ enough for resulting data to be available for service providers to identify and work to address barriers to equitable service delivery. (See also 2.2.8) | Now that ethnicity data is included in clinical and quality monitoring information, ensure the process for identifying and addressing barriers to equitable service delivery is embedded at Rahiri and there is evidence of this occurring. | 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. | The Rahiri activities coordinator provides services for Rahiri’s residents including an existing eight bed dementia unit, with oversight from a diversional therapist based at another New Zealand Age Care Limited facility. The proposed new 12 bed dementia unit is in a separate location. Motivational activities for both groups of people living with dementia cannot be provided at the same time. In order to support all residents at Rahiri with appropriate activities, outings, and prepare, review a | When the new 12 bed dementia unit is approved and occupied, ensure there is an additional time allocated in the roster on a weekly basis for an activities coordinator or diversional therapist to meet the needs of all residents at Rahiri. | PA Low | 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. | On the day of the audit there were not enough trained staff to support an additional 12-bed dementia unit/residents. | Ensure that as soon as approval is given for an additional 12-bed dementia unit, staff members not already enrolled in appropriate training do so, and complete training as soon as possible, to be compliant with the contract for these services. (The timeframe of ‘prior to occupancy’ is for staff to commence training.) | PA Low | Reporting Complete | |
| Where required by legislation, there shall be a Fire and Emergency New Zealand- approved evacuation plan. | Security systems for access into and out of the unit have been identified as a change which is required to the 12-bed wing, for the provision of dementia care. These systems have not yet been installed because the provider is waiting for approval from HealthCert before installing the magnetic locks. | Install the appropriate locks, identified in the contracted provider’s Fire Safety report, on internal connecting doors and the external gate. | 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: Certification Audit
Audit date:
Audit type: Provisional Audit
