Premise details
- Address
- 16 Princes Street Otahuhu Auckland 1062
- Total beds
- 28
- Service types
- Medical, Rest home care, Geriatric
Certification/licence details
- Certification/licence name
- The Willows Home and Hospital Limited - The Willows Home and Hospital
- Current auditor
- The DAA Group Limited
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- The Willows Home and Hospital Limited
- Street address
- 16 Princes Street Otahuhu Auckland 1062
- Postal address
- 16 Princes Street Otahuhu Auckland 1062
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 develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | The quality and risk plan reviewed is documented for 2025. The goals and objectives for 2024 had not been reviewed. The 2025 goals have not been personalised for the facility, with appropriate timeframes to be achieved. Management was currently working on this aspect of service delivery at the time of the audit. | To ensure the quality plan objectives for 2024 are reviewed and the 2025 plan updated to include any unachieved or new goals/objectives for 2025. | PA Low | 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. | The National Adverse Events Reporting Policy was discussed. Management interviewed were not fully aware of the obligations required. Training is needed to comprehend the reporting obligations. | To ensure management are fully informed about the National Adverse Events Reporting Policy 2023 and the obligations to be met. | PA Low | In Progress | |
| The frequency and extent of monitoring of people during restraint shall be determined by a registered health professional and implemented according to this determination. | Restraint monitoring was currently being recorded on one record sheet, and not on the individual record sheets available for the four individual residents using a restraint. | To ensure each resident using a restraint has each episode of monitoring recorded on the appropriate record sheet for each resident. | PA Low | 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. | Collection and analysis of entry and decline rates, including specific data for entry and decline rates for Māori, had not been completed since November 2023. | Ensure collection and analysis of entry and decline rates including specific data for entry and decline rates for Māori is 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 | (i)There was no evidence of completed wound assessments, monitoring forms and wound care plans in resident files reviewed. (ii) Four of five resident files reviewed had resident dietary profiles that were not consistently evaluated six monthly as per policy requirements. | Ensure required documentation is completed as per policy requirements. | PA Low | In Progress | |
| Each episode of restraint shall be evaluated, and service providers shall consider: (a) Time intervals between the debrief process and evaluation processes shall be determined by the nature and risk of the restraint being used; (b) The type of restraint used; (c) Whether the person’s care or support plan, and advance directives or preferences, where in place, were followed; (d) The impact the restraint had on the person. This shall inform changes to the person’s care or support plan, resulting f | Each episode of restraint was documented in the progress records reviewed and not on the evaluation form provided for restraint management. There are no evaluation forms in the four residents’ records to verify the six-monthly reviews have occurred. | To ensure the appropriate restraint evaluation documentation is implemented and is kept in the individual resident’s record. | 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: Certification Audit
