Premise details
- Address
- 2 Insoll Avenue Enderley Hamilton 3214
- Total beds
- 83
- Service types
- Psychogeriatric, Geriatric, Medical, Rest home care
Certification/licence details
- Certification/licence name
- Bupa Care Services NZ Limited - Rossendale Care Home
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- Bupa Care Services NZ Limited
- Street address
- Level 2 109 Carlton Grove Road Newmarket Auckland 1023
- Postal address
- PO Box 113054 Newmarket Auckland 1149
- Website
- http://www.bupa.co.nz/
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 engage with people receiving services to assess and develop their individual care or support plan in a timely manner. Whānau shall be involved when the person receiving services requests this. | (i). Five of six interRAI assessments (three hospital, two PG level) had not been completed within the required timeframes. (ii). Long-term care plans had not been completed within 21 days for one PG level, and two long-term hospital residents. (iii). InterRAI assessments sampled had not been reviewed six-monthly and evaluations were not completed six-monthly or sooner for a change in health condition for two hospital level residents. | (i). -(ii) Ensure an interRAI assessment and long-term care plan are completed within 21 days of admission. (iii). Ensure interRAI reassessments are completed at least six-monthly or earlier when there are significant change in a resident`s heath. | 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). Shortfalls identified through internal audits are not always documented as followed up and/ or closed off. (ii). Meeting minutes do not always document that issues raised in meetings are followed up/ closed off in subsequent meetings. (iii). Health and safety issues are not fully documented and followed at health and safety meetings. | (i)-(iii). Ensure that there is a plan to respond to identified internal and external risks. | PA Low | 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 hospital resident required oxygen therapy which was prescribed appropriately; however, the care plan was not updated to reflect the needs and required interventions and monitoring required. The same resident had no interventions recorded in the long term care plan following frequent behaviours of concern. (ii). One hospital resident did not have detailed interventions documented in relation to PEG and catheter changes or recognition and interventions should a blockage occur. (iii). The | (i)-(ii). Ensure care plans have detailed interventions to provide guidance to staff in the management of care and interventions are updated to reflect changes to a resident`s needs. (iii). Ensure short term acute issues documented in a short term care plan is signed of when resolved. | 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. | (i). Infection control is discussed at staff meetings; however, this audit was unable to evidence any infection control meetings occurred where in-depth data analysis at service level occurred. | (ii). Ensure there is a forum dedicated to the review and discussion of infection control at service level. | PA Low | In Progress | |
| Service providers ensure competent health care and support workers manage medication including: receiving, storage, administration, monitoring, safe disposal, or returning to pharmacy. | (i). Checks of controlled medications documented in the register had not been consistently completed over a five-month period. | (i). Ensure medication checks are consistently carried out as per policy and best practice requirements. | PA Moderate | In Progress | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | (i). Four of five staff files reviewed did not have a current staff appraisal in file. | (i). Ensure that all staff who have been employed for a year or more have a current performance appraisal on file. | 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 | (i). One hospital level resident did not have a care plan updated following the implementation of restraint use, and (ii). Monitoring had not been carried out as per the frequency detailed in the restraint assessment | (i). Ensure care plans have detailed interventions to provide guidance to staff on care management and are updated to reflect changes to resident needs and management plan. (ii). Ensure that monitoring occurs as per policy requirements. | 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 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; Partial Provisional Audit
Audit date:
Audit type: Partial Provisional Audit; Surveillance Audit
Audit date:
Audit type: Partial Provisional Audit
Audit date:
Audit type: Surveillance Audit
Audit date:
Audit type: Certification Audit
