Premise details
- Address
- 37 Carters Terrace Tinwald Ashburton 7700
- Total beds
- 64
- Service types
- Medical, Rest home care, Geriatric
Certification/licence details
- Certification/licence name
- Terrace View Lifecare Limited - Terrace View Retirement Village
- Current auditor
- The DAA Group Limited
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- Terrace View Lifecare Limited
- Street address
- 37 Carters Terrace Tinwald Ashburton 7700
- 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 |
|---|---|---|---|---|---|
| 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. | Five out of six residents’ files sampled for review did not have initial interRAI assessments, medical admission assessments and long-term care plans completed in a timely manner. | Ensure all assessments are completed in the timeframes required by the aged related residential care contract | PA Low | Reporting Complete | |
| Surveillance methods, tools, documentation, analysis, and assignment of responsibilities shall be described and documented using standardised surveillance definitions. Surveillance includes ethnicity data. | Infection surveillance did not include ethnicity data. | Ensure infection surveillance includes ethnicity data to meet the criterion. | 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. | There was no evidence that the scheduled quality and risk meetings have been held monthly since the last audit. There was no evidence of collation or analysis of data or that progress is evaluated against outcomes. | The monthly meetings are reinstated and occur as scheduled. Data is collated and analysed, and progress is evaluated against outcomes. | PA Low | 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. | Four out of six interRAI assessments for recent admissions were not completed within the contractually required timeframe following admission. | Ensure all residents have an interRAI assessment completed withing 21 days of admission as contractually required. | PA Low | Reporting Complete | |
| Service providers shall evaluate progress against quality outcomes. | The facility is not consistently evaluating progress towards meeting the quality outcomes as required by the standard. | Ensure progress towards meeting the quality outcomes is evaluated as required by the standard. | 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 | Resident’s individual and personal strengths, goals and aspirations related to cultural and spiritual needs were not documented in care plans reviewed. | Ensure the personal strengths, goals and aspirations related to cultural and spiritual needs of residents are documented and supports to achieve these personal goals are identified. | PA Low | Reporting Complete | |
| A medication management system shall be implemented appropriate to the scope of the service. | Not all aspects of the medication management system met the required standard. These included: • Expired medications had not been returned to the pharmacy. • Medications were without a pharmacy label to identify the resident’s name, prescription details and administration instructions. • Medications where the pharmacy label was worn and illegible, and as a result the prescriber’s name and administration instructions were not identifiable. • Eye drops and eye ointments had not been discarded | Ensure that all aspects of the medication management system meet the required standard, including the labelling of medications, the return of expired medication to the pharmacy, and that individually dispensed medication is not used as communal ward stock. | PA Moderate | Reporting Complete | |
| 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. | The infection prevention programme had not been approved by governance and had not been reviewed and reported on annually. | Ensure the infection prevention programme is approved by governance and is reviewed and reported on annually. | PA Low | Reporting Complete | |
| There shall be a clinical governance structure in place that is appropriate to the size and complexity of the service provision. | The provider was unable to evidence there was a clinical governance structure in place. | Reinstate the clinical governance structure and ensure the RN meetings are held as required. | PA Low | Reporting Complete | |
| 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. | Training records, including competency records, were not available on the day of the audit and the provider was unable to evidence the required training had been completed. | Ensure training records, including competency records, are located, and that they continue to record completed training as required. | PA Low | Reporting Complete | |
| Surveillance methods, tools, documentation, analysis, and assignment of responsibilities shall be described and documented using standardised surveillance definitions. Surveillance includes ethnicity data. | Infection surveillance data did not include ethnicity data. | Ensure ethnicity data is included in infection surveillance, as required by the standard and as described in policy. | PA Low | 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. | Infection surveillance data had not been reported to governance and recommendations to improve performance had not been identified where necessary and reported to governance. | Ensure the results of infection surveillance and recommendations to improve performance are identified where necessary and reported to governance. | PA Low | 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 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: 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
