Premise details
- Address
- 7 Tui Terrace Tairua 3508
- Total beds
- 44
- Service types
- Medical, Rest home care, Geriatric
Certification/licence details
- Certification/licence name
- Tairua Residential Care Limited - Tairua Residential Care
- Current auditor
- HealthShare Limited
- End date of current certificate/licence
- Certification period
- 24 months
Provider details
- Provider name
- Tairua Residential Care Limited
- Street address
- 7 Tui Terrace Tairua 3508
- Postal address
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 |
|---|---|---|---|---|---|
| Governance bodies shall have meaningful Māori representation on relevant organisational boards, and these representatives shall have substantive input into organisational operational policies. | There is no meaningful Māori representation in the organisation. | Obtain meaningful Māori representation. | 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. | Adverse events are not collated in a manner to provide meaningful analysis and mitigate risk. | Include time and location in the analysis of adverse events. | PA Moderate | 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. | Not all nursing assessments were documented within a timely manner to inform care- plan development. Not all interRAI assessments were current. | Ensure all nursing assessments are completed within a timely manner. Ensure all interRAI assessments are current. | 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. | There are insufficient staff on duty at all times. During the night shift, there were no registered nurses working on the floor, and only two health assistants to cover both wings. The funders agreement requires at least two health assistants on duty at all times in the rest home, and two health care assistants and one registered nurse at all times in the hospital. | Provide sufficient staff to cover all shifts. | 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 | Early warning signs and risks are not always escalated for appropriate assessment and intervention. Clinical records are not consistently integrated | Ensure early warning signs and risks are always escalated for appropriate intervention. Ensure clinical records are consistently integrated. | PA Moderate | Reporting Complete | |
| The decision to approve restraint for a person receiving services shall be made: (a) As a last resort, after all other interventions or de-escalation strategies have been tried or implemented; (b) After adequate time has been given for cultural assessment; (c) Following assessment, planning, and preparation, which includes available resources able to be put in place; (d) By the most appropriate health professional; (e) When the environment is appropriate and safe. | There was insufficient evidence that alternatives to restraint had been trialled or implemented. | Maintain evidence that alternatives to restraint had been discussed and trialled. | PA Moderate | Reporting Complete | |
| The following aspects of the system shall be performed and communicated to people by registered health professionals operating within their role and scope of practice: prescribing, dispensing, reconciliation, and review. | Not all medication files had evidence of a documented three-monthly review by the GP. | Ensure all medication files have a documented three-monthly review by the GP. | 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 | Not all residents had been reviewed by the GP at three monthly intervals. | Ensure all residents are reviewed by the GP at three monthly intervals, or more frequently if required. | PA Moderate | Reporting Complete | |
| Service providers shall understand and comply with statutory and regulatory obligations in relation to essential notification reporting. | Not all essential notifications had been made as required. | Complete essential notification reporting as required. | PA Moderate | Reporting Complete | |
| Service providers shall ensure their health care and support workers can deliver highquality health care for Māori. | The service is currently unable to deliver high quality health care for Māori. | Ensure the service can deliver high quality health care for Māori. | PA Low | Reporting Complete | |
| The nutritional value of menus shall be reviewed by appropriately qualified personnel such as dietitians. | The menu has not been reviewed as required. | Ensure the menu is reviewed. | PA Moderate | Reporting Complete | |
| Surveillance methods, tools, documentation, analysis, and assignment of responsibilities shall be described and documented using standardised surveillance definitions. Surveillance includes ethnicity data. | Surveillance data did not include ethnicity data. | Ensure surveillance data includes ethnicity data. | PA Low | Reporting Complete | |
| An approved food control plan shall be available as required. | The food control plan has not been approved. | Ensure the food control plan is approved. | PA Moderate | Reporting Complete | |
| An approved food control plan shall be available as required. | A food control plan was not available. | Ensure a food control plan is available. | PA Moderate | Reporting Complete | |
| Surveillance methods, tools, documentation, analysis, and assignment of responsibilities shall be described and documented using standardised surveillance definitions. Surveillance includes ethnicity data. | Surveillance reports did not include ethnicity data. | Ensure Surveillance reports include ethnicity 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. | The service does not meet the staffing requirements described in the funding agreement (ARRC) clauses D17.3 and D17.4 (d). There were no registered nurses working on the floor for evening and night shifts and an insufficient number of staff on duty at night. The funders agreement requires at least two care staff on duty at all times in the rest home, and two health care assistants and one registered nurse at all times in the hospital. | Provide sufficient numbers of qualified and experienced staff in both the hospital and rest home on all shifts | PA Moderate | Reporting Complete | |
| Service providers shall understand and comply with statutory and regulatory obligations in relation to essential notification reporting. | Shortage of RNs on shift were not being notified as required. | Ensure that the Ministry of Health-Manatū Hauora is notified of RN shortages on shift at the time periods required. | PA Moderate | Reporting Complete | |
| I shall give informed consent in accordance with the Code of Health and Disability Services Consumers’ Rights and operating policies. | The informed consent form had not been signed in all records. | Ensure the informed consent form is signed in all records. | 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 | Care-plans were not developed for persons admitted for a short stay. Neurological observations were not completed following a resident’s unwitnessed fall consistently. | Ensure care-plans are developed for persons admitted for a short stay. Ensure neurological observations are completed following a resident’s unwitnessed fall. | PA Moderate | Reporting Complete | |
| 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. | Not all staff had documented job descriptions. | Ensure each staff member confirms agreement with their job description by retaining a signed copy of these in their personnel file. | PA Low | Reporting Complete | |
| Service providers ensure competent health care and support workers manage medication including: receiving, storage, administration, monitoring, safe disposal, or returning to pharmacy. | Medication telephone orders were not always managed and/or documented as per the policy. Medication administration did not always occur as per best practice. The controlled medication register and some administration records did not have sample signatures documented. There were expired medications on the emergency trolley. | Ensure telephone orders are managed as per the policy. Ensure medication administration occurs as per best practice. Ensure the controlled drug register and all administration records have sample signatures documented. Ensure medications stored on the emergency remain current. | 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 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
Audit date:
Audit type: Certification Audit
