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Premise details

Address
91 Alan Livingstone Drive RD 1 Cambridge 3493
Total beds
80
Service types
Geriatric, Medical, Dementia care, Rest home care

Certification/licence details

Certification/licence name
Bupa Care Services NZ Limited - St Kilda 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/

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.

Details of corrective actions

Date of last audit: 16 January 2024

Outcome required Found at audit Action required Risk rating Action status Date action reported complete
Service providers shall implement policies and procedures underpinned by best practice that shall include: (a) The process of holistic assessment of the person’s care or support plan. The policy or procedure shall inform the delivery of services to avoid the use of restraint; (b) The process of approval and review of de-escalation methods, the types of restraint used, and the duration of restraint used by the service provider; (c) Restraint elimination and use of alternative interventions shall There were three residents using bedrails as ‘clinical intervention for safety’. Because these three residents are unable to get out of bed but are at risk of rolling out of bed, they are no longer considered being restrained. This is a recent update to Bupa policy and therefore these three residents were taken off the restraint register. Ensure the restraint policy is updated to reflect Ngā Paerewa standard. PA Low Reporting Complete
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 One hospital resident’s long term care plan had not been reviewed for eight’s months and one resident in the dementia unit did not have their care plan reviewed for seven months. Ensure care plan reviews are completed at least 6-monthly as per the ARCC contract and policy. PA Low Reporting 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). One long-term care plan has not been completed within the required time frame and was four weeks overdue. (ii). One resident does not have a long-term care plan. (i). Ensure all long-term care plans are completed within the required timeframe. (II). Ensure all residents have a long-term care plan in place. 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 service does not have sufficient numbers of registered nurses to have a registered nurse on duty at all times in the hospital level care as per ARRC agreement D17.4. Ensure there is adequate coverage of all shifts by a registered nurse to meet the requirements of the ARRC contract D17.4. PA Low Reporting Complete
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 out of four unwitnessed falls did not have neurological observations completed as per policy Ensure all residents who have unwitnessed falls have neurological observations completed as per policy. 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.

About audit reports

Audit reports for this rest home’s latest audits can be downloaded below.

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.

© Ministry of Health – Manatū Hauora