Premise details
- Address
- 4 McKenzie Street Te Puia Springs 4048
- Total beds
- 21
- Service types
- Maternity, Medical, Rest home care, Geriatric
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 |
|---|---|---|---|---|---|
| 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 of an overarching strategic operations plan for the organisation, to ensure the structure, purpose, scope, directions, performance expectations, and goals/objectives are clearly defined, and that the plan is evaluated at planned intervals to review progress. | Ensure the strategic operations plan is completed, approved by governance, and implemented across the organisation. | PA Low | In Progress | |
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | Incident management data is not always being reported on the electronic system available and internal audits are not being completed as per the internal audit schedule. | Ensure accurate information is reported by staff and that internal audits are completed, in order to identify accurate analysis of data and to identify any trends that may be occurring. | 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. | Two out of seven resident files reviewed did not have a care plan documented in a timely manner. This included an initial care plan for an ARCC resident and a care plan for a resident under the medical contact. | Ensure care plans are developed in a timely manner for all residents admitted. | 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 roles and responsibilities for the IPCC role have not been documented. | Document the role and responsibilities for the person responsible for facilitating the infection control programme. | PA Low | 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. | Staff training records are recorded in many different places and are difficult to access when needed. | Ensure staff training and competencies completed are recorded for each staff member on their personal records, and are accessible. | 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 | Registered nurses did not have access to all applicable interRAI assessment data for individual residents, limiting their ability to ensure strategies were sufficiently identified to support residents to meet their own goals. There was no clear process in place to ensure long-term care plans were updated following interRAI assessments. The support of residents required to achieve their individually identified goals was not sufficiently documented, including early warning signs and associated ris | Ensure InterRAI assessments are consistently used to inform the care planning process. Ensure care plans are updated and sufficiently detailed to include individual resident strengths and goals, including early warning signs and risks, and the support required to achieve these is clearly documented and communicated. | 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. | There is no process in place to record and routinely analyse service entry and decline rates, including rates for Māori. | Implement a process to record and analyse resident entry and decline rates and include rates for Māori. | PA Low | In Progress | |
| Service providers shall have a clearly defined and documented IP programme that shall be: (a) Developed by those with IP expertise; (b) Approved by the governance body; (c) Linked to the quality improvement programme; and (d) Reviewed and reported on annually. | An annual review of the infection control programme has not occurred. | Ensure that the infection prevention programme is reviewed at least annually. | PA Low | 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. | Ensure resident care is provided to residents that is consistent with their assessed needs, including: a) Residents who have unwitnessed falls have neurological observations assessed in a timely and consistent manner. b) A process is implemented to ensure the weight of long-term care residents is monitored appropriately. c) Ensure the vital signs of acute medical residents are consistently monitored at a frequency appropriate for the resident’s clinical needs. | PA Moderate | In Progress | |
| Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided. | Staff interviewed stated that they received orientation at the commencement of employment; however, there was no record of orientation/induction occurring in seven of seven staff individual records reviewed. | Ensure a record of orientation/induction at commencement of employment is documented on the individual staff record when completed. | PA Low | 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 | Care plans were not updated to reflect changing resident long-term care needs. Short-term changes in care needs were not consistently documented. For example, when residents had an infection. Activities are provided; however, it is difficult from records available to assess if these meet the residents’ needs. | Ensure care plans are updated to reflect individual residents’ changes in care. Implement a process to document short-term care needs for ARRC residents. Ensure documentation related to the activities programme enables evaluating whether individual resident needs are being met. | PA Moderate | In Progress | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | Staff performance appraisals were not being completed in a timely manner as per the organisation’s human resources policy. | Ensure the annual staff appraisals are completed, and a record is maintained in the individual staff records. | PA Low | 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. | Restraint management and the restraint register had not been reviewed, and no training on the least restrictive practice, the use of restraint, alternative cultural-specific interventions, and de-escalation had been provided to staff since the previous audit. | Ensure restraint is reviewed annually and that staff receive the appropriate training required to meet this standard. | PA Low | In Progress | |
| Service providers shall ensure that the environment is clean and there are safe and effective cleaning processes appropriate to the size and scope of the health and disability service that shall include: (a) Methods, frequency, and materials used for cleaning processes; (b) Cleaning processes that are monitored for effectiveness and audit, and feedback on performance is provided to the cleaning team; (c) Access to designated areas for the safe and hygienic storage of cleaning equipment and chemi | There is no current process in place to monitor/audit the effectiveness of the cleaning programme and provide feedback on performance to the cleaning team. | Implement a process to monitor/audit the effectiveness of the cleaning programme and provide feedback to applicable staff. | PA Low | In Progress | |
| An approved food control plan shall be available as required. | The verification audit of the food control plan is overdue by nine months. | Ensure the food control plan verification audits occur within the required time frames. | PA Low | In Progress | |
| Service providers shall ensure there are safe and effective laundry services appropriate to the size and scope of the health and disability service that include: (a) Methods, frequency, and materials used for laundry processes; (b) Laundry processes being monitored for effectiveness; (c) A clear separation between handling and storage of clean and dirty laundry; (d) Access to designated areas for the safe and hygienic storage of laundry equipment and chemicals. This shall be reflected in a writt | A process was not being implemented to monitor the effectiveness of laundry processes. | Ensure a process is implemented to monitor the effectiveness of laundry processes. | PA Low | In Progress | |
| Service providers will demonstrate a clear process for early consultation and involvement from the IP personnel or committee during the design of any new building or when significant changes are proposed to an existing facility. | There was not a process in place to ensure IPC is consulted when significant changes occur to the facility/building. | Ensure IPC is consulted when significant changes are planned or occur to the facility/building. | 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 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: 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
Audit date:
Audit type: Surveillance Audit
