Premise details
- Address
- 19 Clachan Grange Road East Taieri Mosgiel 9024
- Total beds
- 20
- Service types
- Medical, Rest home care, Geriatric
Certification/licence details
- Certification/licence name
- The Grange Care Limited - The Grange
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 24 months
Provider details
- Provider name
- The Grange Care Limited
- Street address
- 19 Clachan Grange Road East Taieri Mosgiel 9024
- Postal address
- 19 Clachan Grange Road East Taieri Mosgiel 9024
- Website
- https://www.thegrangelifecare.nz/
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 |
|---|---|---|---|---|---|
| There shall be a clinical governance structure in place that is appropriate to the size and complexity of the service provision. | i). The clinical governance structure is not yet in place. ii). The quality plan has not been signed off by owners/directors which includes restraint management and infection prevention and control. | i). Ensure the development of a clinical governance structure appropriate to the size and complexity of The Grange. ii). Ensure quality plans and information are signed off by the owners/directors. | 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. | i). Meetings are not occurring as planned, two staff meetings have been held, one clinical meeting and no residents/family/whānau meetings. ii). There was no documented evidence of consistent monthly collation, or analysis of quality data. iii). There was no documented evidence of sharing quality data information with staff (other than the meetings held in December and April). iv). Internal audits have not been evidenced as being completed as scheduled since opening in July 2023 – March 2024. | i). Ensure meetings for staff, clinical, resident, family/whānau meetings are held as scheduled. ii). Ensure quality data collation is evidenced as being collated, analysed as per policy. iii). Ensure there is documented evidence of discussions held with staff around quality data collated and corrective actions identified. iv). Ensure the internal audits are completed as scheduled. | 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. | i). Two of five (one rest home and one hospital ) resident files did not evidence an initial GP visit within contractual requirements. ii). Five residents (two rest home, three hospital) had not had a long-term care plan documented within 21 days of admission. iii). Two residents (one hospital and one rest home) had no initial interRAI completed within 21 days. iv). One rest home resident was overdue for an interRAI reassessment. | i). Ensure the GP completes an initial visit within five days of admission. ii). - iv). Ensure interRAI assessments, reassessments, and care plans are documented and reviewed within expected timeframes. | PA Moderate | 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 clinical care manager was not able to evidence recent (within the past year) external education on infection prevention and control. | Ensure the clinical care manager as the infection prevention and control coordinator has completed external education on infection prevention and control. | 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 | i). One hospital resident did not include sufficient interventions to guide care around restraint, behaviour management, mobility, skin care, continence, end of life cares, pain, seizure management, care of a sub-cutaneous line and nutrition. ii). One hospital resident did not have interventions documented to manage specific mobility requirements, pain, a high falls risk, behaviour management, restraint, and end of life cares. iii). One hospital resident with assessed triggers of mobility, a hi | i). - v). Ensure all care plan interventions are current, individualised and reflect the assessed needs of residents. | PA Moderate | In Progress | |
| A medication management system shall be implemented appropriate to the scope of the service. | i). There is no documented monitoring of medication room or fridge temperatures. ii). Room temperatures in six resident rooms were set at 26 degrees and each residents medication is stored in a locked drawer in the residents’ rooms. iii). Three prescription creams in current use with recommended timeframes for use did not evidence opening dates were in use. iv). Two eye drops stored in the residents locked drawer were not dated on opening. v). Three decanted midazolam sprays in current use we | i).& ii). Ensure fridge and room temperatures are consistently monitored as per policy and legislation. iii). - v). Ensure eye drops, creams and midazolam sprays are stored and discarded as per manufacturer’s instructions. vi).& vii.). Ensure controlled drug stock checks occurs per legislative requirements | PA Moderate | In Progress | |
| Service providers shall follow the National Adverse Event Reporting Policy for internal and external reporting (where required) to reduce preventable harm by supporting systems learnings. | i). There was no documented evidence of timely RN reviews in the 12 incident and accident forms reviewed. ii). Opportunities to minimise future risks were not documented. | i). & ii). Ensure RN reviews are being evidenced as being conducted in a timely manner and opportunities to minimise risks are evidenced as identified and implemented. | 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 | i). Monthly monitoring (paper and electronic) of weights were not commenced until March despite residents being admitted seven months previously. ii). There was no documented monitoring of repositioning, restraint monitoring, food and fluid intake, behaviour charts following wandering or verbal and physical aggression for the residents who required this. iii). Six of seven wound charts do not reflect comprehensive assessments, treatment plans or monitoring. iv). Frequency of wound dressings hav | i)-ii). Ensure monitoring is documented as required. iii). Ensure wound charts reflect comprehensive assessments, treatment plans or monitoring. iv). Ensure wound dressings occur as scheduled. | PA Moderate | In Progress | |
| I shall have the right to make an informed choice and give informed consent. | The informed consent forms in five files reviewed had not been signed. | Ensure all residents have a signed consent forms on file as per policy. | PA Low | In Progress | |
| 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. | There is not always a member of staff with a current first aid certificate on duty at all times. | Ensure there is at least one member of staff with a current first aid certificate on duty at all times. | 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 | i). One hospital residents care plan was overdue for the routine six-month evaluation. ii). The care plan evaluation that had been completed did not reflect the residents progression towards meeting their goal. | i). & ii). Ensure the care plan evaluations are completed within expected timeframes and evidence residents progression towards meeting their goals. | PA Low | In Progress | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | The three-monthly appraisal was not evidenced in the files of the three staff files. | Ensure appraisal schedules are met for all staff. | PA Low | In Progress | |
| Executive leaders shall report restraint used at defined intervals and aggregated restraint data, including the type and frequency of restraint, to governance bodies. Data analysis shall support the implementation of an agreed strategy to ensure the health and safety of people and health care and support workers. | i). The service has not reported the use of current restraints at staff meetings, quality reports or owners/director meetings. ii). The service has not analysed current restraint data and reported this to the owners/ directors. | i). & ii). Ensure restraint is reported to governance and data is analysed | PA Moderate | In Progress | |
| Service providers shall implement policies and procedures underpinned by best practice that shall include: (a) The process of holistic assessment of the person’s care or support plan. The policy or procedure shall inform the delivery of services to avoid the use of restraint; (b) The process of approval and review of de-escalation methods, the types of restraint used, and the duration of restraint used by the service provider; (c) Restraint elimination and use of alternative interventions shall | Restraint policies and procedures around restraint assessments, and approval have not been implemented | Ensure restraint policies and processes are implemented as documented | PA Moderate | In Progress | |
| Each episode of restraint shall be documented on a restraint register and in people’s records in sufficient detail to provide an accurate rationale for use, intervention, duration, and outcome of the restraint, and shall include: (a) The type of restraint used; (b) Details of the reasons for initiating the restraint; (c) The decision-making process, including details of de-escalation techniques and alternative interventions that were attempted or considered prior to the use of restraint; (d) If | i). The service has an electronic restraint register available for use; however, this has not been utilised. ii). Three of three care plans reviewed of residents using restraint did not evidence an implemented process including assessment related to identify potential risks. iii). The use of restraint, and interventions for safe use were not documented in the residents care plan for all three residents utilising bed rails as restraint. iv). Three of three care plans reviewed of residents using | i). Ensure the electronic restraint register available for use. ii). Ensure assessments are appropriately utilised to identify potential risks. iii). Ensure there are interventions around the use and management of restraints and these are documented in the care plans. iv). Ensure monitoring requirements are clearly documented and implemented. | PA Moderate | 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: Certification Audit
Audit date:
Audit type: Partial Provisional Audit
