Premise details
- Address
- 621 Aberdeen Road Te Hapara Gisborne 4010
- Total beds
- 97
- Service types
- Dementia care, Rest home care, Geriatric, Medical
Certification/licence details
- Certification/licence name
- Heritage Lifecare Limited - Te Wiremu House
- Current auditor
- The DAA Group Limited
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- Heritage Lifecare Limited
- Street address
- 16 Johnsonville Road Johnsonville Wellington 6037
- Postal address
- PO Box 13223 Johnsonville Wellington 6440
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 |
|---|---|---|---|---|---|
| The facilitation of safe self-administration of medicines by consumers where appropriate. | One resident who was self-administering medicines did not have their competency reviewed in a timely manner as per the organisation’s policy. | Provide evidence that self-medication administration procedures are completed as per the organisation’s policy. | PA Moderate | Reporting Complete | |
| A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines. | Outcomes of PRN medicines administered in 15 out of 18 medication charts sampled were not consistently documented. | Ensure administered PRN medicines are evaluated for effectiveness. | PA Moderate | Reporting Complete | |
| A medication management system shall be implemented appropriate to the scope of the service. | Two of three medication room temperature monitoring were not completed as per policy requirements. | Ensure medication room temperature monitoring is completed as per policy and legislation requirements. | 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 | (i) While incidents are being reported and immediate action is being taken, the ongoing individualised actions to prevent recurrence are not consistently documented in applicable resident care plans sampled in relation to falls and behaviours that challenge, or on occasions linked to the care plan evaluation and review process. (ii) Post-fall assessments are not consistently completed in applicable sampled resident records. There are multiple documents available, both electronic and paper-based | Ensure post-fall assessments and behaviour management strategies are consistently documented and linked to the care plan evaluation process. | 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. | Records are not available to demonstrate that all staff have completed Te Wiremu House competency requirements. For example, donning and doffing personal protective equipment, hand hygiene, and standard precautions. | Ensure staff complete annual competencies as required by policy and appropriate records are retained to demonstrate this. | 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. | While there is a registered nurse on duty at all times as required by the ARRC contract, the number of RNs rostered each day does not meet the organisation’s RN staffing requirements. There are at least two care staff working in the secure dementia unit for longer than 18 months that have not yet completed an industry-approved qualification in dementia level care. There are insufficient cleaning hours worked on the weekend days for the size of the facility. There are challenges recruiting for m | Continue the recruitment process for registered nurses, caregivers and kitchen assistant positions so staffing requirements can be met. Ensure care staff working in the secure dementia level care unit start and complete an industry-approved qualification in dementia care within 18 months of employment. Increase rostered cleaning hours on the weekend. | 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: Certification Audit
Audit date:
Audit type: Surveillance Audit
