Premise details
- Address
- 295 Brockville Road Brockville Dunedin 9011
- Total beds
- 28
- Service types
- Medical, Rest home care, Geriatric
Certification/licence details
- Certification/licence name
- Little Sisters of The Poor Aged Care New Zealand Limited - Sacred Heart Home & Hospital
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- Little Sisters of The Poor Aged Care New Zealand Limited
- Street address
- 295 Brockville Road Brockville Dunedin 9011
- Postal address
- PO Box 47276 Ponsonby Auckland 1144
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) The internal audit schedule has not been fully implemented with 15 planned audits not completed over the previous 12 months; (ii) Three monthly staff meetings have been held once in 2022 (June) and once in 2023 (July); (iii) Meeting minutes do not evidence discussion of quality data. | (i). Ensure the internal audit schedule is fully implemented. (ii) Ensure staff meetings are held as scheduled (iii) Ensure staff meeting minutes reflect discussion of quality data | 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. | Two shifts per week do not evidence a RN on duty | Ensure a RN is rostered on all shifts to meet have a registered the requirements of the ARC contract D17.3 e i-viii. | PA Low | Reporting Complete | |
| Service providers shall implement systems to determine and develop the competencies of health care and support workers to meet the needs of people equitably. | Annual competencies have not been completed for moving and handling | Ensure all competencies are completed as per policy | PA Low | Reporting Complete | |
| 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. | Not all 2 yearly mandatory training has been completed around code of rights, privacy, confidentiality, challenging behaviour, and emergency management. | Ensure that all mandatory training requirements are completed 2 yearly. | PA Low | Reporting Complete | |
| A medication management system shall be implemented appropriate to the scope of the service. | Ten of the twelve electronic medication charts reviewed did not have a current photograph to enable resident identification. | Ensure all photographs are current. | PA Low | Reporting Complete | |
| 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 | Shortfalls were noted in two of the four long-term care plans where the interventions to ensure care and support is provided are absent or limited in the information provided for the caregivers. i). In one rest home resident’s file the need to decrease weight is identified in the medical notes; however, interventions for managing weight are limited and do not include dietary management strategies such as including dietary high fibre and increasing exercise/attending the residents exercise progra | Ensure interventions for i) and ii) are in the residents’ care plan to guide the caregivers in the care and support they provide. | PA Low | Reporting Complete | |
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | (i). Corrective actions required to address non- conformities were not always documented and addressed for audits completed between January to September 2024. (ii). The staff, registered nurse and care givers meetings did not always occur as scheduled between January 2024 to October 2024. (iii). Meeting minutes between January 2024 and October 2024 reviewed did not always evidence discussion of quality data. | (i). Ensure corrective actions to address non- conformities related to planned internal audits are documented and addressed. (ii). Ensure meetings (staff, clinical staff, and care givers) occur as scheduled. (iii). Ensure meeting minutes evidence discussion of quality data with staff. | PA Moderate | In Progress | |
| A medication management system shall be implemented appropriate to the scope of the service. | (i). Outcomes following the use of `as required` medications were not documented in three of the ten medication charts reviewed. (ii). Weekly controlled drugs stock counts have not been consistently completed. | (i). Ensure outcomes are recorded for all `as required` medications. (ii). Ensure weekly controlled drugs stock counts 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 | Insufficient interventions were documented in four of the five files reviewed. The following shortfalls were noted: (i). Two hospital resident’s care plan had insufficient interventions to manage mood (anxiety and behaviour). (ii). One rest home resident’s care plan did not note non-therapeutic management of chronic back pain. (iii). Two hospital resident’s care plans had insufficient evidence to manage intimacy. | (i)-(iii). Ensure there is sufficient information/ interventions to guide caregivers in the care of the residents` needs. | PA Moderate | In Progress | |
| Service providers shall implement systems to determine and develop the competencies of health care and support workers to meet the needs of people equitably. | (i). Wound management and syringe driver competencies have not been completed for registered nurses. (ii). The schedule for annual manual handling competencies was not implemented as required. | (i)-(ii). Ensure competencies are completed as per the competency schedule. | PA Moderate | 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). One hospital level resident with intermittent behaviour has no monitoring chart completed to record intermittent challenging behaviour. (ii). One hospital and one rest home resident had unwitnessed falls; the neurological observations were not completed as per the policy timeframes. (iii). Two hospital residents progress notes were not completed daily by the registered nurse to review implementation of care. | (i). Ensure residents that exhibit intermittent challenging behaviour have a behaviour chart completed. (ii). Ensure neurological observations are completed as per policy timeframes following unwitnessed falls. (iii). Ensure registered nurses complete daily progress notes for hospital level residents. | 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). Topics related to management of challenging behaviour, wound care, sexuality and intimacy have not been completed as scheduled. | (i). Ensure all training topics 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 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
