Premise details
- Address
- 10 MacMurray Road Remuera Auckland 1050
- Total beds
- 35
- Service types
- Physical, Rest home care, Geriatric, Medical
Certification/licence details
- Certification/licence name
- Remuera Rest Home and Hospital Limited - Remuera Rest Home and Hospital
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 12 months
Provider details
- Provider name
- Remuera Rest Home and Hospital Limited
- Street address
- 8 Roxburgh Street Newmarket Auckland 1023
- Postal address
- PO Box 109077 Newmarket Auckland 1149
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 there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services. | (i). The service continues not to have enough registered nurses to have a registered nurse on duty at all times as per the ARC contract D17.4 a. i (ii). The service does not have enough cleaning and kitchen staff to ensure provision of culturally and clinically safe service provision. | (i). Ensure a registered nurse is always on duty to meet the requirements of the ARC contract D17.4 a. i. (ii). Ensure there are enough cleaning and kitchen staff for the roster to ensure service provision. | PA Moderate | In Progress | |
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | (i). Resident and staff satisfaction surveys have not been evidenced as being completed since last audit. (ii). Resident meetings have not been evidenced as being completed since last audit. | (i). & (ii). Ensure staff, resident and family/whanau surveys and resident meetings evidenced as being held as scheduled. | PA Low | In Progress | |
| Service providers shall evaluate progress against quality outcomes. | There is no evidence of analysis of incidents/accident events and infections, restraint, benchmarking, implementation of quality improvements and evaluation of actions to ensure continuous quality improvement of service delivery. | Ensure systems and processes are in place to ensure analysis and evaluation of quality data. | PA Low | In Progress | |
| Service providers shall develop and implement policies and procedures in accordance with good employment practice and meet the requirements of legislation. | (i). Six of six staff files did not have evidence to demonstrate that police checks were completed. (ii). Four of six files do not evidence reference checks being completed. | (i). & (ii). Ensure that there is evidence of police and reference checks completed | PA Low | In Progress | |
| The physical environment, internal and external, shall be safe and accessible, minimise risk of harm, and promote safe mobility and independence. | (i). Flooring internally and paving in outside areas accessed by residents is uneven in places. (ii). There is no documented maintenance plan in place | (i). Ensure flooring and paving is even surfaced. (ii). Ensure a maintenance plan is documented and implemented. | 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. | Training has not been completed as per annual education and training schedule to meet standards and contractual requirements. | Ensure training is completed to meet standard and contractual requirements | 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 | Review of neurological observation charts following unwitnessed falls showed six of nine had insufficient neurological monitoring. | Ensure neurological monitoring post unwitnessed falls follows best practice and policy. | PA Low | In Progress | |
| Service providers shall understand and comply with statutory and regulatory obligations in relation to essential notification reporting. | The service has not completed section 31 notifications for registered nurse shortage since last audit | Ensure statutory and regulatory obligations in relation to essential notification is completed. | PA Low | In Progress | |
| Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided. | One healthcare assistant and one cleaner did not evidence of completed orientation on file. | Ensure that there is evidence of orientation completed on file. | PA Low | In Progress | |
| My service provider shall practise open communication with me. | Eleven of 12 incidents reviewed do not provide documented evidence of family/whanau, EPOA notification following incidents/accidents. | Ensure there is documented evidence of family/ whanau notification following incidents. | PA Low | In Progress | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | Four of four staff (two healthcare assistants, one registered nurse and one cook) who have been employed for over one year did not have current performance appraisals on file. | Ensure that staff have appraisals completed as scheduled. | PA Low | In Progress | |
| My complaint shall be addressed and resolved in accordance with the Code of Health and Disability Services Consumers’ Rights. | (i). Ensure that there is evidence to demonstrate escalation point in complaint responses. (ii). Ensure that there is evidence of satisfaction / dissatisfaction of outcome by complainant. | (i). & (ii). Ensure complaints processes are fully implemented in line with guidelines set by the Health and Disability Commissioner (HDC). | PA Low | In Progress | |
| Each episode of restraint shall be documented on a restraint register and in people’s records in sufficient detail to provide an accurate rationale for use, intervention, duration, and outcome of the restraint, and shall include: (a) The type of restraint used; (b) Details of the reasons for initiating the restraint; (c) The decision-making process, including details of de-escalation techniques and alternative interventions that were attempted or considered prior to the use of restraint; (d) If | A current restraint register was not sighted. | Ensure there is an up-to-date restraint register in place. | PA Low | In Progress | |
| Service providers shall facilitate safe self-administration of medication where appropriate. | (i). One resident who self-medicates has not had a competency assessment. (ii). Since they attend their own general practitioner staff are unaware of what medications are prescribed. (iii). Medications were sighted stored in an open drawer in their bedroom. | (i).- (iii). Ensure the policy for self-medication is followed. | PA Moderate | In Progress | |
| Service providers shall ensure that the environment is clean and there are safe and effective cleaning processes appropriate to the size and scope of the health and disability service that shall include: (a) Methods, frequency, and materials used for cleaning processes; (b) Cleaning processes that are monitored for effectiveness and audit, and feedback on performance is provided to the cleaning team; (c) Access to designated areas for the safe and hygienic storage of cleaning equipment and chemi | (i). The facility has a distinct residual odour in the rooms, corridors and carpeted areas even post cleaning. (ii). There is no designated sluice /sanitizer for safe and appropriate decontamination and sanitisation of equipment. | (i). Ensure the environment is clean and odour controlled. (ii). Ensure there is a designated area for sluice and sanitisation. | PA Low | In Progress | |
| Service providers shall ensure there are safe and effective laundry services appropriate to the size and scope of the health and disability service that include: (a) Methods, frequency, and materials used for laundry processes; (b) Laundry processes being monitored for effectiveness; (c) A clear separation between handling and storage of clean and dirty laundry; (d) Access to designated areas for the safe and hygienic storage of laundry equipment and chemicals. This shall be reflected in a writt | Materials used for laundry processes do not provide assurance for decontamination and minimisation of the risk of transmission of infection. Interview with staff and observation on the day of the audit confirm the use of over-the-counter detergent (with no anti-bacterial and anti-viral properties), a warm or cold wash cycle for laundry and machines with no ability for high contaminate cycle. | Ensure laundry materials are fit for purpose and provide assurance for minimisation of infection transmission. | PA Low | In Progress | |
| All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal shall comply with current legislation and guidelines. | (i). Records of freezer temperatures show from 30 July to present one of the freezers is not below -18 degrees Celsius daily. (ii). Dry stored food did not have a label with the date of opening and dry goods were not decanted into covered and sealed containers. (iii). The kitchen refrigerator doors were sticky. | (i). Ensure corrective action is taken when freezer temperatures are out of recommended range. (ii). Ensure correct labelling and storage of dry goods. (iii). Ensure stringent cleaning throughout kitchen. | PA Low | In Progress | |
| Where required by legislation, there shall be a Fire and Emergency New Zealand- approved evacuation plan. | The fire evacuation plan is not approved by Fire and Emergency New Zealand as some corrective actions have not been completed. | Ensure corrective actions identified are completed to obtain approval for the fire evacuation plan. | PA Moderate | Reporting Complete | |
| A medication management system shall be implemented appropriate to the scope of the service. | (i). There was food stored in the medication fridge. (ii). The room temperature of the medication room was not evidenced as being monitored. | (i). Ensure the medication fridge only contains medications. (ii). Ensure the temperature of the medication room is monitored. | PA Moderate | Reporting Complete | |
| Alternative essential energy and utility sources shall be available, in the event of the main supplies failing. | (i). There is no alternative energy source. (ii). The BBQ was currently out of order. (iii). There is insufficient stored water available. | (i). – (iii). Ensure there is an alternative energy source and sufficient water stored for main utility outage. | 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. | There is no evidence to demonstrate that the manager has completed orientation for the role and training in relation to managing an aged care facility. | Ensure orientation and training for the role is completed. | 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.
