Premise details
- Address
- 9 Tweed Street Herne Bay Auckland 1011
- Total beds
- 31
- Service types
- Rest home care, Medical, Geriatric
Certification/licence details
- Certification/licence name
- Little Sisters of The Poor Aged Care New Zealand Limited - St Joseph's
- 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 |
|---|---|---|---|---|---|
| Buildings, plant, and equipment shall be fit for purpose, and comply with legislation relevant to the health and disability service being provided. The environment is inclusive of peoples’ cultures and supports cultural practices. | The testing and tagging for the hoist chargers is not up to date. | Ensure all electrical equipment is included in the testing and tagging process. | 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).The triggers and interventions are not documented on one hospital level resident’s long-term care plan; this same resident’s long term care plan does not document the need to be supervised when in the lounge (noting these are implemented in practice). (ii).One hospital level resident’s long term care plan does not document the need for two hourly monitoring, the use of a sensor mat (noting they are both implemented) and the preference for female only care staff (also implemented). | (i)-(ii).Ensure that there are detailed interventions to provide guidance to staff in the delivery of care needs. | 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 | Four of four fall related incidents reviewed all documented that neurological observations had not been document according to time frames in the policy and / or were incorrectly completed (staff writing ‘asleep’ at night). | Ensure the neurological observations are completed with time frames set by policy and the documentation reflects the policy and neurological observation template. | PA Low | In Progress | |
| Planned review of a person’s care or support plan shall: (a) Be undertaken at defined intervals in collaboration with the person and whānau, together with wider service providers; (b) Include the use of a range of outcome measurements; (c) Record the degree of achievement against the person’s agreed goals and aspiration as well as whānau goals and aspirations; (d) Identify changes to the person’s care or support plan, which are agreed collaboratively through the ongoing re-assessment and review | Where there has been a change to the resident’s needs/ condition short term care plans (or changes to the long-term care plan) have not always been documented, this includes: three residents with a wound or a bruise (one rest home and two hospital) did not have a short-term care plan documented. One hospital level resident with a medication trial had no short-term care plan in place to direct staff around care and monitoring. | Ensure that, where progress is different from expected, or acute/ short term changes to care are required, there are documented changed to the long- term care plan or a short-term care plan documented. | 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. | Five of seven staff files did not have evidence of completed role specific orientation. | Ensure that there is evidence of staff orientation on file. | PA Low | In Progress | |
| Surveillance methods, tools, documentation, analysis, and assignment of responsibilities shall be described and documented using standardised surveillance definitions. Surveillance includes ethnicity data. | Surveillance of infection does not include ethnicity data. | Ensure that ethnicity data is linked to infection surveillance. | 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).There is no evidence of signed employment agreement /variation for one staff with dual roles; and (ii). No signed job description for the main role they are undertaking. | (i).-(ii).Ensure required employment documentation is in place for staff with dual roles reflecting roles they work. | PA Low | Reporting Complete | |
| A medication management system shall be implemented appropriate to the scope of the service. | (i).The fridge in the medication room contained out of date: eye drops, and expired laxatives. (ii).The nurse-initiated medication process is not formalised to include medications approved by the GP including indications for use and time frames. | (i).Ensure all medications stored are within date. (ii).Ensure the nurse-initiated medication process is formalised and approved by the GP. | PA Moderate | 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 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
Audit date:
Audit type: Certification Audit
