Summerville Rest Home

Premise details

Address: 411 Frederick Street Mahora Hastings 4120
Total beds: 16
Service types: Rest home care

Certification/licence details

Certification/licence name: Sunflower Field NZ Limited - Summerville Rest Home
Current auditor: BSI Group New Zealand Ltd
End date of current certificate/licence: 9 December 2027
Certification period: 36 months

Provider details

Provider name: Sunflower Field NZ Limited
Street address: 411 Frederick Street Mahora Hastings 4120
Postal address: 19A Knightsbridge Drive Forrest Hill Auckland 0620

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.

Details of corrective actions

Date of last audit: 26 March 2026
Outcome required	Found at audit	Action required	Risk rating	Action status	Date action reported 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.	The provider is yet to recruit a diversional therapist or an activities coordinator to plan, facilitate and implement a formal activities programme that enhances residents’ strengths, skills, and interests.	Ensure a formal activities programme is implemented that enhances the residents’ strengths, skills and interests.	PA Moderate	In Progress
Alternative essential energy and utility sources shall be available, in the event of the main supplies failing.	The provider is yet to formalise a written plan that ensures the facility will be provided a generator in the event of the power supply failing.	Ensure the plan in place for accessing a generator when required is formalised and shared with all staff.	PA Low	Reporting Complete	11/02/2025
Service providers demonstrate routine analysis to show entry and decline rates. This must include specific data for entry and decline rates for Māori.	There is no evidence of a process in place to collate and analyse ethnicity data in relation to entry and decline rates.	Ensure there is a process implemented to collate and analyse ethnicity in relation to entry and decline rate.	PA Low	Reporting Complete	11/02/2025
During the initial engagement prior to service entry, service providers shall ensure: (a) There is accurate information about the service available in a variety of accessible formats; (b) There are documented entry criteria that are clearly communicated to people, whānau, and, where appropriate, local communities and referral agencies.	The provider is yet to implement processes that ensures the resident entry criteria is clearly communicated to people, their family/whānau, local communities and referral agencies.	Ensure a process is implemented so that all information pertaining to resident entry criteria is clearly communicated to people, their family/whānau, local communities and referral agencies at all times.	PA Low	Reporting Complete	11/02/2025
Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care.	(i) Policies and procedures have not been reviewed as scheduled and do not cover all aspects of the Ngā Paerewa NZS 8134:2021. (ii) Meeting minutes did not address key components of the service delivery.	(i) Ensure policies and procedures are reviewed to meet current policy and legislative requirements. (ii) Ensure meetings minutes addresses key components of the service delivery.	PA Moderate	Reporting Complete	6/03/2025
Service providers shall develop and implement policies and procedures in accordance with good employment practice and meet the requirements of legislation.	All staff files reviewed did not evidence that police vetting was undertaken.	Ensure there is documented evidence of police vetting undertaken as part of the pre-employment process.	PA Moderate	Reporting Complete	6/03/2025
Service providers shall ensure the skills and knowledge required of each position are identified and the outcomes, accountability, responsibilities, authority, and functions to be achieved in each position are documented.	Four out of five staff files reviewed had no position descriptions in place.	Provide evidence of signed position descriptions for all staff.	PA Moderate	Reporting Complete	6/03/2025
Health care and support workers shall have the opportunity to discuss and review performance at defined intervals.	All five staff files reviewed had appraisals that were not signed to confirm staff involvement.	Ensure all completed performance appraisals are signed to confirm staff have been involved in the process.	PA Moderate	Reporting Complete	6/03/2025
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.	The provider is yet to recruit a diversional therapist or an activities coordinator to plan, facilitate and implement a formal activities programme that enhances residents’ strengths, skills and interests.	Ensure a formal activities programme is implemented that enhances the residents' strengths, skills, and interests.	PA Moderate	Reporting Complete	6/03/2025
My complaint shall be addressed and resolved in accordance with the Code of Health and Disability Services Consumers’ Rights.	All complaint forms reviewed did not evidence the investigation, communication of outcomes, or documentation of satisfaction in response to the complaint by the complainant	Ensure that any complaint is investigated, and the complainant informed of the outcome as per policy.	PA Low	Reporting Complete	3/06/2025
Surveillance methods, tools, documentation, analysis, and assignment of responsibilities shall be described and documented using standardised surveillance definitions. Surveillance includes ethnicity data.	Monthly surveillance of infections does not include ethnicity data.	Ensure monthly surveillance of infections includes ethnicity data.	PA Low	Reporting Complete	3/06/2025
Governance bodies shall ensure service providers’ structure, purpose, values, scope, direction, performance, and goals are clearly identified, monitored, reviewed, and evaluated at defined intervals.	Progress towards the achievement of documented business goals is not evidenced in the business plan reviewed.	Ensure that review of goals documented in the business plan occurs at regular intervals.	PA Moderate	Reporting Complete	3/06/2025
During the initial engagement prior to service entry, service providers shall ensure: (a) There is accurate information about the service available in a variety of accessible formats; (b) There are documented entry criteria that are clearly communicated to people, whānau, and, where appropriate, local communities and referral agencies.	The provider is yet to implement a process that ensures the resident entry criteria is clearly communicated to people, their family/whānau, local communities and referral agencies.	Ensure a process is implemented so that all information pertaining to resident entry is clearly always communicated to people, their family/whānau, local communities and referral agencies.	PA Moderate	In Progress
Governance bodies shall ensure service providers’ structure, purpose, values, scope, direction, performance, and goals are clearly identified, monitored, reviewed, and evaluated at defined intervals.	There was no evidence provided that validated that the goals documented in the business plan have been reviewed at regular intervals.	Ensure evidence is provided that the business plan is current and that the goals have been reviewed at regular intervals.	PA Moderate	In Progress
Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care.	i) Not all policies and procedures were made available to the auditor and could not be verified that progress has been made, and the policies align with Ngā Paerewa NZS 8134:2021. ii) In one of two resident incident accident event forms reviewed (unwitnessed falls) next of kin had not been informed. iii) In two of four incident/accident events there was no follow up by the registered nurse. In addition, one behaviour event was documented in the resident’s progress notes, but no related incident	i) Ensure all policies and procedures are reviewed and align with Ngā Paerewa Health and Disability Services Standards (NZS8134:2021). ii) Ensure all post fall management protocols are followed for all unwitnessed falls. iii) Ensure all resident incident/accidents are documented appropriately, followed up by a registered nurse, appropriate monitoring put in place where required, and changes made to care plans that reflect the change of care needs for the resident.	PA Moderate	In Progress
Service providers shall develop and implement policies and procedures in accordance with good employment practice and meet the requirements of legislation.	Five out of five staff records did not evidence that police vetting was undertaken.	Ensure there is documented evidence of police vetting undertaken as part of the pre-employment process.	PA Moderate	In Progress
The physical environment, internal and external, shall be safe and accessible, minimise risk of harm, and promote safe mobility and independence.	Repairs are required in one resident bathroom, which can only be used by residents who are not cognitively impaired. There is no safety signage, no hazard identification documented.	Ensure where there is a delay in repairs, and identified hazards are noted there is appropriate signage and warning to reduce risk of harm.	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	Early warning signs and risks that may adversely affect a person’s wellbeing are inconsistently recorded, with insufficient information documented that focuses on prevention or escalation for appropriate intervention.	Ensure all resident care plans document early warning signs, interventions to guide prevention and escalation where appropriate.	PA Moderate	In Progress
Service providers shall ensure the skills and knowledge required of each position are identified and the outcomes, accountability, responsibilities, authority, and functions to be achieved in each position are documented.	Five of five staff records reviewed did not have a position description in place.	Provide evidence of signed position descriptions for all staff.	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.	The provider is yet to develop and implement a system that ensures all staff have the required competencies to meet the needs of all people equitably.	Ensure a system is developed and implemented that ensures all staff have the required competencies to meet the needs of all people equitably.	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.	The provider has no process in place that enables identification of external and internal risks and opportunities, including potential inequities.	Ensure policy and procedure is implemented that guides staff in the identification of external and internal risks and develops a plan to respond to them.	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	Residents changing care needs are inconsistently documented in care plans.	Ensure all resident’s care needs are documented in their care plans in a timely fashion.	PA Moderate	In Progress
Service providers demonstrate routine analysis to show entry and decline rates. This must include specific data for entry and decline rates for Māori.	The provider is yet to implement a system that ensures ethnicity data is collated and analysed in relation to entry and decline rates.	Ensure there is a process implemented to collate and analyse ethnicity data.	PA Moderate	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.	Review of five staff files and training records, and discussion with the clinical manager evidenced that a training schedule is yet to be implemented that covers mandatory/annual training appropriate to the service delivered.	Ensure a training programme is developed and implemented so that staff have the skills required to provide high quality safe services.	PA Moderate	In Progress
Service providers shall follow the National Adverse Event Reporting Policy for internal and external reporting (where required) to reduce preventable harm by supporting systems learnings.	The provider does not have policy and process in place that ensures the National Adverse Event Reporting Policy and Severity Assessment Code (SAC) reporting procedures are followed post all serious events to reduce preventable harm by supporting systems learnings. There is no plan in place that clearly outlines all the clinical managers responsibilities in the absence of the owner/manager.	Ensure policy and procedure are implemented and followed and all serious events are reported appropriately to guide improvements in care. Ensure a clear plan is in place in the absence of the owner/manager that ensures the day-to-day management of the facility is not interrupted.	PA Moderate	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	All five care plans met the required admission timeframes for completion, however three of five had not been reviewed within defined intervals. Three of five did not have a current interRAI completed within required timeframes or when changes had occurred for the resident. Neurological observations were incomplete for one incident form completed following a residents unwitnessed fall. Three of five did not identify changes to the person’s care or support plan following an event or change in the	Ensure all resident care plans are completed, and updated, to maintain required timeframes or when changes are required to meet the residents care needs.	PA Moderate	In Progress
Health care and support workers shall maintain professional boundaries with me and refrain from acts or behaviours that could negatively impact on my wellbeing.	Staff do not sign a code of conduct during their onboarding process, have training in or sign documents ensuring they are aware of professional boundaries and refrain from acts or behaviours that could impact negatively on residents’ wellbeing.	Ensure the onboarding process for all staff includes signing a code of conduct.	PA Moderate	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)One staff member continues to administer medication despite not completing their annual competency which is overdue. ii) The medication trolley is stored in the staff room. This is often left unlocked. Medications that cannot fit int the trolley are left on top.	i)Ensure all staff who administer medication retain their medication competency. ii)Always ensure the safe storage of all medications	PA Moderate	In Progress
Service providers shall understand and comply with statutory and regulatory obligations in relation to essential notification reporting.	The provider does not comply with statutory and regulatory obligations in relation to essential notification reporting.	Ensure the service develops and implements process that ensures they comply with their obligations in relation to essential notifications.	PA Moderate	In Progress
Health care and support workers shall have the opportunity to discuss and review performance at defined intervals.	Three of five staff files reviewed did not have an appraisal on record, two of five had an appraisal but it was not dated or signed by the staff member.	Ensure all staff records evidence a completed, current appraisal that are signed to confirm staff have been involved in the process.	PA Moderate	In Progress
Surveillance methods, tools, documentation, analysis, and assignment of responsibilities shall be described and documented using standardised surveillance definitions. Surveillance includes ethnicity data.	Monthly surveillance of infections does not include ethnicity data.	Ensure monthly surveillance of infections includes ethnicity data.	PA Moderate	In Progress
My complaint shall be addressed and resolved in accordance with the Code of Health and Disability Services Consumers’ Rights.	Two complaints did not evidence they had been investigated, that outcomes were clearly documented and the complaint could be closed to the satisfaction of the complaints. All complaints remain open at time of audit.	Ensure all complaints are addressed and resolved in accordance with the Code of Health and Disability Services Consumer’s Rights.	PA Moderate	In Progress
Health care and support workers shall be trained in least restrictive practice, safe practice, the use of restraint, alternative cultural-specific interventions, and de-escalation techniques within a culture of continuous learning.	The provider is yet to develop and implement a full training schedule for care staff which includes least restrictive practice, alternative cultural specific interventions, and de-escalation techniques.	Ensure appropriate training is provided for staff in relation to restraint.	PA Low	In Progress
An approved food control plan shall be available as required.	The provider was unable to produce evidence of a current food control plan being in place.	Ensure a current food control plan is in place.	PA Low	In Progress
I am informed of the findings of my complaint.	Review of three complaints did not evidence the complainant was satisfied with the outcome so the complaint could be closed.	Ensure complaints policy and process is implemented and followed and all complaints are only closed when the complainant is satisfied with the outcome.	PA Moderate	In Progress
Service providers shall facilitate safe self-administration of medication where appropriate.	One resident was known to be buying their own pain relief and self-administering this. The medical practitioner was not aware; no regular screening was being completed to ascertain why the resident felt it necessary to take the medication and nor was it documented.	Ensure residents only self-administer their medication following policy and procedure.	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 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: 26 March 2026

Audit type: Surveillance Audit

Audit date: 27 September 2024

Audit type: Certification Audit

Audit date: 10 May 2023