Premise details
- Address
- 4 McKenzie Street Te Puia Springs 4048
- Total beds
- 21
- Service types
- Medical, Rest home care, Geriatric, Maternity
Certification/licence details
- Certification/licence name
- Ngati Porou Oranga - Te Whare Hauora o Ngati Porou
- Current auditor
- The DAA Group Limited
- End date of current certificate/licence
- Certification period
- 24 months
Provider details
- Provider name
- Ngati Porou Oranga
- Street address
- 4 McKenzie Street RD 1 Tokomaru Bay 4079
- Postal address
- PO Box 2 Te Puia Springs 4048
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 |
|---|---|---|---|---|---|
| Service providers shall ensure their health care and support workers have the skills, attitudes, qualifications, experience, and attributes for the services being delivered. | Registered Nurses are not currently trained to complete InterRAI assessments. | Ensure Registered Nurses are trained in InterRAI | PA Low | In Progress | |
| 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 CNM at Ngāti Porou Hauora is the interim ICN, until the new RN with a post graduate certificate in infection control commences employment in a week. The interim ICN has had no education in IP or AMS. | Provide evidence the ICN has education in IP and AMS. | PA Moderate | In Progress | |
| Service providers, shall evaluate the effectiveness of their AMS programme by: (a) Monitoring the quality and quantity of antimicrobial prescribing, dispensing, and administration and occurrence of adverse effects; (b) Identifying areas for improvement and evaluating the progress of AMS activities. | There is no AMS programme in place to evaluate the effectiveness of the AMS programme. | Provide evidence the AMS programme monitors antimicrobial prescribing and identifies areas for improvement. | PA Moderate | In Progress | |
| 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. | There are two areas in the maternity annexe; one in the labour and birthing room and one in a recessed area where resources are stored where the ceiling tiles have collapsed. There is also mould on the ceiling of one of the postnatal rooms. The maternity annexe smells strongly of dampness. In addition to this there is a ceiling plasterboard that is partially separated from the ceiling overhead of where staff would be working in an emergency. This area is a risk to staff. None of the areas had be | Ensure a plan of action is developed and implemented to address the areas of concern and that a copy is sent through to HealthCERT. | PA High | Reporting Complete | |
| Service providers ensure competent health care and support workers manage medication including: receiving, storage, administration, monitoring, safe disposal, or returning to pharmacy. | Medicines were stored securely, although there was no evidence to verify medicines are stored within the recommended temperature range. | Provide evidence medications are stored within the required range. | PA Moderate | 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 | In implementing care, the needs of residents who had experienced an unwitnessed fall did not have a post fall or ongoing neurological assessment completed. | Provide evidence that residents who experience an unwitnessed fall have a post fall and ongoing neurological assessment completed. | PA Moderate | Reporting Complete | |
| Service providers shall ensure health care and support workers are able to provide a level of first aid and emergency treatment appropriate for the degree of risk associated with the provision of the service. | Whilst there is a plan for all staff to be first aid and emergency trained, this requires implementation. | To ensure staff are trained in first aid and emergency treatment training and to ensure a first aider is on duty for all shifts in the hospital due to the complexity and nature of services provided. | PA Low | Reporting Complete | |
| Service providers, through their IP role or personnel, shall determine the type of surveillance required and the frequency with which it is undertaken, taking into account the size and setting of the service and national and regional surveillance programmes and guidelines. | There is no documentation identifying the types of infections to be surveyed. | Provide evidence there is documentation that identifies the type of infections to be surveyed. | 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. | There is no surveillance documentation that identifies the surveillance process. | Provide evidence that there is a surveillance programme that describes methods, documentation, analysis, and assignment of responsibilities. | PA Moderate | Reporting Complete | |
| Service providers shall have a documented AMS programme that sets out to optimise antimicrobial use and minimising harm. This shall be: (a) Appropriate for the size, scope, and complexity of the service; (b) Approved by the governance body; (c) Developed using evidence-based antimicrobial prescribing guidance and expertise (which includes restrictions and approval processes where necessary and access to laboratory diagnostic testing reports). | Ngāti Porou Hauora, at the time of audit, had no evidence to verify a commitment to AMS. | Provide evidence there is an AMS programme operating at Ngāti Porou Hauora. | PA Moderate | Reporting Complete | |
| Results of surveillance and recommendations to improve performance where necessary shall be identified, documented, and reported back to the governance body and shared with relevant people in a timely manner. | There is no analysis of the results of surveillance. Results are not shared with staff and the governing body. | Provide evidence there is analysis of the results of surveillance and results are shared with staff and the governing body with recommendations to improve performance. | PA Moderate | Reporting Complete | |
| Surveillance activities shall be appropriate for the service provider and take into account the following: (a) Size and complexity of the service; (b) Type of services provided; (c) Acuity, risk factors, and needs of the people receiving services; (d) Health and safety risk to, and of, the workforce; (e) Systemic risk to the health and disability system as a whole. | There were no surveillance activities were being undertaken. | Provide evidence surveillance of infections in accordance with the services being provided, was being undertaken. | 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. | This area of improvement from the previous audit remains open. The work being completed in the maternity annexe is still in progress and the management staff interviewed stated that it will not be completed until the end of February 2025. A plan is in place to repair the ceiling in the emergency room after the birthing annexe is completed. | To ensure the repair and renovations of the maternity annexe are completed in a timely manner and that work planned for the emergency room is undertaken as soon as possible. | PA Low | In Progress | |
| 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. | Seven files reviewed identified either no care plans or no updated care plans in place to guide residents’ care. | Provide evidence residents have up-to-date care plans documented in a timely manner to guide their care. | PA Moderate | 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 | The support the residents require to achieve their goals was not documented. InterRAI assessments are not being completed in the required timeframes. | Ensure that the InterRAI assessments are completed within the required timeframes. Provide evidence care plans document the support required to achieve the residents’ goals. | 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 | The residents’ care was not always consistent with the residents’ assessed needs. | Provide evidence the care provided to the residents is consistent with their needs. Residents having unwitnessed falls have neurological observations consistent with the facility’s policy. Wound care treatments are documented as they are provided. | 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 records of staff who had completed the required competencies to meet the needs of people equitably were not available at audit. | To ensure all training records can be accessed and verified for each staff member employed. | PA Low | In Progress | |
| Service providers ensure competent health care and support workers manage medication including: receiving, storage, administration, monitoring, safe disposal, or returning to pharmacy. | The room where the medication trolley and the CD drugs are kept require the room temperature to be monitored. Staff administering medications need to be verified as competent to do so. The required six-monthly check of CD drugs needs to occur and be recorded. When CD drugs are administered the two people involved in checking the medication need to ensure the correct resident receives the medication. | Provide evidence that: • all staff administering medications are competent to do so • the temperature of the room where controlled drugs and the drug trolley are kept is monitored to ensure its below 25 degrees Celsius • the two nurses checking out the controlled drugs go to the bedside to ensure the right drug is going to the right person • the required six-monthly check of the controlled drugs is undertaken. | 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 | A planned review of care is not being undertaken at defined intervals, and changes not documented where required. | Provide evidence that care plans are in place, and reviewed six-monthly or as the residents’ need change. | PA Moderate | In Progress | |
| Service providers, shall evaluate the effectiveness of their AMS programme by: (a) Monitoring the quality and quantity of antimicrobial prescribing, dispensing, and administration and occurrence of adverse effects; (b) Identifying areas for improvement and evaluating the progress of AMS activities. | The effectiveness of the AMS programme has not been evaluated. | Provide evidence the effectiveness of the AMS programme has been evaluated. | PA Moderate | In Progress | |
| Service providers shall understand Māori constructs of oranga and implement a process to support Māori and whānau to identify their own pae ora outcomes in their care or support plan. The support required to achieve these shall be clearly documented, communicated, and understood. | Despite staff supporting Māori residents and whānau to identify their own pae ora, this is not being documented on the care plans. | Ensure that Māori residents’ pae ora outcomes are documented on the individual care plans to meet their individual needs. | PA Low | 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 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
