Premise details
- Address
- 16 Princes Street Otahuhu Auckland 1062
- Total beds
- 29
- 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
- 24 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 identify and implement appropriate security arrangements relevant to the people using services and the setting, including appropriate identification. | There is no evidence documenting that residents are aware and/or have been provided information about the CCTV cameras in the building. | To provide evidence to ensure that all residents are aware of the CCTV cameras in the building. | PA Low | Reporting Complete | |
| Service providers ensure competent health care and support workers manage medication including: receiving, storage, administration, monitoring, safe disposal, or returning to pharmacy. | I. Four doses of PRN medicines were administered in 72 hours and there was no documented evidence that the effectiveness was monitored. II. Ten of the 10 medication charts reviewed had no medication reconciliation completed in the last two months. | I. All PRN medicine administered is to be monitored and documented for effectiveness. II. All medications received from the pharmacy are to have medication reconciliation completed and documented in the individual resident’s medication chart. | 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. | There are insufficient health care assistant hours to cover the current residents admitted and their high acuity of care required on an afternoon shift. | To ensure that there is adequate health care assistant support/hours to meet the requirements for up to and including the current 26 residents. | PA Moderate | Reporting Complete | |
| 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 | There is a risk of cross infection to staff and residents in regard to current laundry practices. | To ensure safe handling of dirty laundry. | 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 the five files reviewed had interRAI assessments completed after 21 days of admission into the facility. | Residents are to have their interRAI assessment completed within 21 days of admission. | PA Moderate | Reporting Complete | |
| My service provider shall ensure my services are operating in ways that are culturally safe. | Residents that identify as Māori do not have their Māori cultural needs identified in their care plan. | To ensure that all residents that identify as Māori have their Māori cultural needs identified in their care plan. | PA Low | Reporting Complete | |
| 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 that changes were initiated in the care plan when residents progress was different from expected. II. Short term care plans were not completed for acute conditions. III. The residents' identified needs are not reflected in the care plans. IV. Six monthly care plan evaluations are overdue. V. Māori residents do not have a Māori health care plan. VI. InterRAI outcome measures are not used to support care plan goals and interventions. | I. Where progress is different from expected changes to care plan needs to be initiated. II. All acute condition requires a short-term care plan. III. Residents care plan needs to reflect the resident's current needs as identified in the interRAI assessment. IV. All care plans are to be evaluated every six months. V. Cultural needs for Māori need to be specifically identified and documented in care plans. VI. InterRAI outcome measures are to be used to support care plan goals and interventions | PA Moderate | Reporting Complete | |
| There shall be clear processes for communicating the decisions for declining entry to a service. | There is no clear process of managing and communicating the decisions for declining entry to service. | To have a system which has a clear process for communicating the decisions for declining entry to a service. | 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. | The majority of meeting minutes for the last 12 months did not show evidence of detailed discussions and actions discussed. Resident meetings do not occur. No one was able to understand and/or interpret the handwritten analysis completed for monthly infections. | To ensure that all meeting minutes reflect detailed discussions and actions discussed. To ensure that resident meetings occur. To ensure that handwritten documents are legible. | PA Low | Reporting Complete | |
| Meaningful activities shall be planned and facilitated to develop and enhance people’s strengths, skills, resources, and interests, and shall be responsive to their identity. | There is no evidence of individualised activities programme. | Service provider to ensure there is a system in place to develop and enhance resident's strengths, skills and interests which is responsive to their identity e.g., an activities calendar. | PA Low | Reporting Complete | |
| Service providers shall evaluate progress against quality outcomes. | Not all quality is evaluated for outcomes and not all corrective actions are signed off as closed. | To ensure that all quality outcomes are evaluated, and corrective actions are implemented then signed of as closed. | PA Low | Reporting Complete | |
| Governance bodies shall ensure compliance with legislative, contractual, and regulatory requirements with demonstrated commitment to international conventions ratified by the New Zealand government. | The service has five or more residents under the age of 65 years and does not have residential physical disability included in the scope of certification. | Apply to HealthCERT to have physical disability included in the scope of certification. | PA Moderate | Reporting Complete | |
| 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. | Training on restraint elimination, alternatives and de-escalation techniques has not occurred since 2019 in the staff training records provided. | Ensure staff are provided with training on restraint elimination, alternatives and de-escalation techniques as part of the ongoing education and competency framework. | PA Moderate | Reporting Complete | |
| Meaningful activities shall be planned and facilitated to develop and enhance people’s strengths, skills, resources, and interests, and shall be responsive to their identity. | No evidence of an individualised activities programme. | Provide evidence of an individualised activities programme. | PA Moderate | Reporting Complete | |
| Service providers shall evaluate progress against quality outcomes. | Incident/quality outcomes and internal audits are not sufficiently evaluated, and system improvements/corrective actions identified, implemented, monitored and reviewed for effectiveness. There is inadequate analysis of incident-related information, including themes and trends. | Ensure adverse events/incidents are sufficiently evaluated to identify themes, trends and systems improvements/corrective actions. Ensure corrective actions are consistently identified following internal audits, implemented and monitored for effectiveness. | PA Moderate | Reporting Complete | |
| 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 current competencies as required by organisation policy including medication competency. | Ensure all staff have current competencies as relevant to their role, responsibilities and in accordance with organisation policy. Ensure records are available to demonstrate staff achievement. | PA Moderate | Reporting Complete | |
| A medication management system shall be implemented appropriate to the scope of the service. | (i) Medication room temperature monitoring was not completed as required. (ii) Expired PRN medications were currently in use and kept in the drug trolley and medication room. | (i) Ensure medication room temperatures are completed as per policy and current accepted standards of practice. (ii) Ensure expired PRN medications are not used and returned to the pharmacy in a timely manner. | PA Low | Reporting Complete | |
| Service providers shall understand and comply with statutory and regulatory obligations in relation to essential notification reporting. | Not all section 31 notifications have occurred to relevant authorities as required. | Ensure all applicable events are reported to relevant authorities and agencies in a timely manner and records are retained to demonstrate this process. | PA Moderate | 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. | 1.A staff training plan for 2023 and 2024 could not be located. 2.Records are not available to demonstrate that staff have access to regular ongoing education that includes all topics to align with Ngā Paerewa standards and the age-related residential care contract. 3.The owner has not attended eight hours of education related to managing an agreed related residential care service in the last 12 months. | 1.Develop a training plan/calendar for 2024. 2.Ensure there is an education programme in place that provides staff with regular ongoing education opportunities to meet Ngā Paerewa standards and the age-related residential care contract requirements. 3.Ensure the owner (manager) attends at least eight hours of education related to managing an age-related residential care service annually. | PA Moderate | Reporting Complete | |
| Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided. | Three out of five staff records reviewed did not have evidence staff had completed orientation requirements. | Ensure all new staff complete a role-specific orientation and records are retained. | 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. | (i)Records were not available to demonstrate that all residents had current interRAI assessments in place. (ii)Two of the five residents' files reviewed had no completed interRAI assessments in place. | Ensure records of completed interRAI assessments are available on request and residents who require an interRAI assessment have one completed in a timely manner. | PA Moderate | Reporting Complete | |
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | The staff meeting minutes do not show sufficiently detailed discussion on quality and risk activities and results of internal audits. Resident meetings do not have a template agenda or list of discussion topics to be covered at each meeting for consistency. There is no evidence of follow-up to documented resident requests. | Ensure the minutes of staff meetings are sufficiently detailed to inform staff on the outcomes from the quality and risk monitoring programme and actions required. Develop and implement a consistent agenda or minute template for resident meetings and ensure there is evidence of action taken in response to applicable resident requests. | PA Moderate | Reporting Complete | |
| 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) Some of the outcome scores from interRAI assessments were not identified on long-term care plans and there were no appropriate interventions to address this. (ii) There were no Pacific health plans developed for residents who identify as Pasifika. (ii) Resident nutritional profiles were not reviewed six-monthly as required. (iv) Neurological monitoring of residents post unwitnessed falls was not occurring as per policy requirements. (v) Turning charts were not consistently completed as pe | (i) Ensure all outcome scores from assessments are identified with relevant interventions developed. (ii) Ensure residents who identify as Pasifika have a Pacific health plan in place. (iii) Complete residents' nutritional profiles six-monthly as required. (iv) Ensure neurological observations are completed post unwitnessed falls or when there is a suspected head injury. (v) Consistently complete turning charts as per policy requirements. (vi) Ensure an assessment, consent and monitoring process | 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. | There was no evidence of an annual review of the IP programme. | Ensure that the IP programme is reviewed annually to meet the standard requirement. | PA Low | Reporting Complete | |
| Governance bodies shall demonstrate commitment toward eliminating restraint. | Organisation policy has a commitment to eliminating the use of restraint. However, at governance and operational level restraints are being used and there is a misunderstanding of what restraint is. Restraint use is being incorrectly reported in most staff meeting minutes as having been eliminated/no use of restraint. | Ensure managers/governance understanding of restraint aligns with Ngā Paerewa. Ensure accurate information on the restraint elimination strategy is accurately reported on in staff meeting minutes. | 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 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
