Premise details
- Address
- 18 Glen Road Stokes Valley Lower Hutt 5019
- Website
- http://www.bupa.co.nz/care-homes/care-homes/choose-a-care-home/wellington/stokeswood-rest-home-and-hospital/
- Total beds
- 87
- Service types
- Dementia care, Rest home care, Geriatric, Medical
Certification/licence details
- Certification/licence name
- Bupa Care Services NZ Limited - Stokeswood Rest Home & Hospital
- 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 |
|---|---|---|---|---|---|
| A medication management system shall be implemented appropriate to the scope of the service. | (i). Medication room and fridge temperature monitoring has not been completed consistently as per policy in the dementia medication room and the rest home medication storage cupboard. | (i). Ensure temperature monitoring of medication rooms and fridge are completed consistently as per policy. | PA Moderate | Reporting Complete | |
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | (i). Full staff meetings, RN/Clinical meetings and weekly clinical review meetings have inconsistently occurred for 2023/2024. (ii). The following meetings have not occurred at all for 2023-2024: head of department meetings, infection control and restraint meetings, resident and family meetings. (iii). The three environmental audits were not completed for 2023. (iv). The satisfaction included a low activities satisfaction. Quality initiatives have not been completed/ implemented . (v). Quality i | (i)-(ii). Ensure meetings occur as scheduled. (iii). Ensure audits are completed as scheduled. (iv)-(v). Ensure there is documented evidence of quality initiatives where improvement is required. (vi). Ensure meeting minutes reflect discussion of quality data, restraint outcomes and corrective actions are discussed with staff. | PA Moderate | Reporting Complete | |
| There is an IP role, or IP personnel, as is appropriate for the size and the setting of the service provider, who shall: (a) Be responsible for overseeing and coordinating implementation of the IP programme; (b) Have clearly defined responsibility for IP decision making; (c) Have documented reporting lines to the governance body or senior management; (d) Follow a documented mechanism for accessing appropriate multidisciplinary IP expertise and advice when needed; (e) Receive continuing education | The infection control officer is new to their role (1 month) and has not yet received induction and training for the role. | Complete the infection control officer induction and training for their role and responsibilities. | PA Low | Reporting Complete | |
| Alternative essential energy and utility sources shall be available, in the event of the main supplies failing. | There is no documented process in place to check the civil defence equipment at regular intervals | Ensure civil defence equipment/supplies are checked at regular intervals. | PA Low | Reporting Complete | |
| Meaningful activities shall be planned and facilitated to develop and enhance people’s strengths, skills, resources, and interests, and shall be responsive to their identity. | (i). One staff was on leave and another who had recently left their role, neither were replaced on the roster. The activities programme was facilitated by one activity person across the service for at least two weeks. There was no activities person on the second day of the audit for the care home. (ii). No current or historic activity planner was available for the dementia unit for the auditors to view. | (i). Ensure that the key workers are replaced to ensure continuity of facilitation of the activities programme. (ii). Ensure there is a documented activity programme. | 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 | Five (three hospital, one dementia and one rest home), of seven resident files reviewed, of residents who have been in the care home for more than six months, did not have care evaluations/ progression towards goals completed six monthly | Ensure care evaluations are completed at least six monthly and document the progression towards meeting goals | 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 | (i). One hospital resident interRAI assessment and care plan interventions were not reflective of the current resident status in relation to mobility and nutrition as observed during the audit, as per staff interviews and progress notes reviewed. The same resident did not have a behaviour plan for behaviours identified in the progress notes and as identified during staff interviews. (ii). One hospital and one rest home resident did not have detailed interventions documented in relation to manag | (i)- (vii) Ensure care plans include interventions to support all assessed needs including acute changes in health status. | PA Moderate | Reporting 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. | i). The communal toilets in the dementia unit are not able to be locked to ensure privacy. ii). The door to the outside garden in the dementia unit was locked on the morning of the first day of audit. iii). There were bedrooms in the dementia units with high snip locks on the door, with the ability to prevent entry or exit of resident from their room. | i). Ensure there is a process to respect resident privacy in the communal toilets. ii). Ensure resident are able to access the outside garden in the dementia unit. iii). Ensure there are no locks on bedrooms doors. | PA Moderate | 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 | i). Two hospital and one rest home level of care resident did not have interventions related to falls prevention and mobility assistance. ii). One rest home and one dementia unit resident file did not have interventions for behaviours that challenge, including increasing confusion for the rest home resident. iii). One dementia unit resident’s care plan did not include interventions for a high risk of dehydration. iv). One rest home and one dementia level of care resident did not have a short-ter | i). – v). Ensure care plans include interventions to support all assessed needs, including acute changes in health status. | PA Moderate | Reporting Complete | |
| Where required by legislation, there shall be a Fire and Emergency New Zealand- approved evacuation plan. | The most recent six-monthly trial evacuation drill was not able to be evidenced on the days of audit. | Ensure that records are maintained of trial fire evacuations. | 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 | i). Five of five neurological observations were not completed as per policy post unwitnessed fall. ii). One dementia level resident did not have weight monitoring and flood and fluid charting as per instruction. iii). One rest home level resident did not have twice daily pain monitoring as requested by the GP. | i). -iii). Ensure that care interventions are undertaken as per policy / instruction. | PA Low | Reporting Complete | |
| An approved food control plan shall be available as required. | The kitchenettes for each of the units had unlabelled/ mislabelled and/ or undated food stored. | Ensure all food is safely stored with correct labels and dates according to the policy and food control plan. | 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 evidence of a documented process in place to check the civil defence equipment at regular intervals. ii). The civil defence equipment was not able to be located on the days of audit. | i). Ensure civil defence equipment/supplies are checked at regular intervals. ii). Ensure the civil defence equipment/ supplies are located and easily accessible. | PA Moderate | Reporting Complete | |
| Meaningful activities shall be planned and facilitated to develop and enhance people’s strengths, skills, resources, and interests, and shall be responsive to their identity. | i). Activities in the dementia unit have not been delivered as per plan, as sighted on the day of audit. ii). There were no facilitated activities noted in the hospital lounge with residents sitting and watching TV on separate occasions observed. iii). Care staff stated they are not provided with instruction and resources to provide activities in the absence of the activity team. | i). & ii). Ensure that meaningful activities are provided for residents. iii). Ensure that staff are provided with instruction and resources to provide activities in the absence of the activity staff. | PA Moderate | 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. | Interviews with staff and review of the roster shows that staff absences are not consistently covered. Over a two-week period, 15 shifts were not covered across the different roles of staff in the care home. | Ensure that staff are replaced for planned and short notice absences. | 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). Meetings have not been completed as scheduled since last audit. ii). Internal audits have not been completed as scheduled. iii). Corrective actions have not been consistently developed for internal audits, where compliance was not at expected level. iv). Where corrective actions have been developed, there is no evidence to demonstrate follow up, implementation, and sign off when completed. v). Outcomes and actions from audits have not been consistently discussed with staff during meetings. | i). -ii). Ensure meetings and internal audits are completed as scheduled. iii)- iv). Ensure corrective actions are developed, implemented, and signed off when completed. v). Ensure outcomes of audits are discussed with staff. | PA Moderate | Reporting Complete | |
| Service providers shall ensure safe and appropriate storage and disposal of waste and infectious or hazardous substances that complies with current legislation and local authority requirements. This shall be reflected in a written policy. | Chemicals were stored in the cupboards that do not have locks in the hospital, rest home, and dementia kitchenettes. | Ensure chemicals are safely stored in locked cupboards at all times. | PA Low | Reporting Complete | |
| Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided. | Four of six staff did not have evidence of completed orientation on file. | Ensured that there is evidence of completed orientation. | PA Moderate | Reporting Complete | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | Four of four staff files do not have evidence of completed performance appraisals. | Ensure that there is evidence of completed performance appraisals. | PA Moderate | 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 | Two hospital, one secure dementia and one rest home resident file did not document progress towards stated goals as part of the evaluation process. | Ensure care evaluations document the progression towards meeting goals. | 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: Surveillance Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Surveillance Audit
