Thornton Park Retirement Lodge

Premise details

Address: 137 State Highway 35 RD 1 Opotiki 3197
Total beds: 43
Service types: Rest home care, Geriatric, Medical

Certification/licence details

Certification/licence name: Thornton Park Retirement Village Limited - Thornton Park Retirement Lodge
Current auditor: BSI Group New Zealand Ltd
End date of current certificate/licence: 11 January 2027
Certification period: 24 months

Provider details

Provider name: Thornton Park Retirement Village Limited
Street address: 137 State Highway 35 RD 1 Opotiki 3197
Postal address: PO Box 550 Opotiki 3162

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.

Details of corrective actions

Date of last audit: 05 November 2024
Outcome required	Found at audit	Action required	Risk rating	Action status	Date action reported complete
Surveillance methods, tools, documentation, analysis, and assignment of responsibilities shall be described and documented using standardised surveillance definitions. Surveillance includes ethnicity data.	Ethnicity data is not being collated and analysed during infection surveillance.	Ensure ethnicity data is collated and analysed during infection surveillance.	PA Low	In Progress
Governance bodies shall have demonstrated expertise in Te Tiriti, health equity, and cultural safety as core competencies.	The owner and manager have not yet completed competencies in relation to Te Tiriti o Waitangi and cultural safety	Ensure the owner and manager completed cultural competencies.	PA Low	In Progress
Governance bodies shall ensure service providers’ structure, purpose, values, scope, direction, performance, and goals are clearly identified, monitored, reviewed, and evaluated at defined intervals.	A current business/ strategic plan could not be located during the audit.	Ensure a business/ strategic plan is available.	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). Not all meetings have been evidenced as being held as scheduled in 2024; caregiver meetings have been held in June, July and August; an all staff meeting was held in September; a health and safety meeting was held in May. ii). There was no evidence of kitchen, housekeeping, maintenance, staff training meetings held in 2024. iii). The quality meetings are held over the phone weekly between the management and the owner, which evidenced discussion around occupancy and current issues, and did no	i). & ii). Ensure meetings are held as scheduled. iii). & iv). Ensure quality data is discussed with the owner and the staff, the manager and owner.	PA Moderate	In Progress
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 was no RN cover for nine shifts over the two-week roster reviewed which does not meet the requirements of the ARRC contract D17.4 (a-i).	Ensure there is RN cover 24/7 to meet the requirements of the ARRC contract D17.4 (a-i).	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). One hospital level resident at high risk of aspiration, on an enteral feeding regime via PEG, and having deep suction did not have initial assessments, initial care plan, or a care plan in place despite being in the service for over 6 months. ii). One rest home resident did not have an initial assessment, initial care plan, or long-term care plan developed within the required timeframes. iii). One rest home resident did not have an interRAI assessment completed with 21 days of entering the s	i). - iv). Ensure care plans and all assessments are completed within the required timeframes	PA Moderate	In Progress
My service provider shall design a Pacific plan in partnership with Pacific communities underpinned by Pacific voices and Pacific models of care.	There was no Pacific Health plan or policy available at the time of the audit.	Ensure a Pacific health plan and/or policy is developed in partnership with Pasifika and is available to staff.	PA Low	In Progress
Service providers shall evaluate progress against quality outcomes.	i). Meeting minutes of the meetings that have been held did not evidence of a review of the previous minutes or closure of any matters arising from the previous meeting. ii). Of the 22 internal audits completed, eight did not have corrective action plans in place. iii). Ten corrective action plans had not been signed off as resolved or ongoing and did not document who was responsible for this. iv). There was no evidence in the meeting minutes reviewed that corrective actions are discussed with	i). Ensure there is evidence of matters arising being closed off from previous meetings. ii). - iv). Ensure corrective actions are identified, responsibility of closure is assigned, and corrective actions are evidenced as being discussed in meeting minutes. v). Ensure areas of low satisfaction have corrective actions identified in satisfaction surveys.	PA Low	In Progress
Care or support plans shall be developed within service providers’ model of care.	One resident who identified as Māori did not have a cultural assessment or Māori health plan completed	Ensure cultural assessments and Māori health needs are detailed.	PA Low	In Progress
The physical environment, internal and external, shall be safe and accessible, minimise risk of harm, and promote safe mobility and independence.	No long-term maintenance plan was available on the day of audit.	Ensure preventative maintenance tasks on a long-term maintenance plan	PA Low	In Progress
A medication management system shall be implemented appropriate to the scope of the service.	The medication fridge and medication room temperatures have been monitored daily; however, fridge temperatures were outside the acceptable range 10 times in the previous month with no corrective actions documented.	Ensure corrective actions are documented and implemented as per policy and best practice guidelines	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.	i). There was no evidence of a policy in relation to competencies staff are required to complete. ii). There was no record of the competencies staff have completed over the last year.	i). & ii). Ensure the policy is available, competencies are defined, and a record is maintained.	PA Low	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 nurse manager who oversees infection control, and the two assistant coordinators (internationally qualified nurses) have not completed any form of infection control related education or training in order to perform the role.	Ensure those overseeing and implementing the infection control programme have the requisite level of knowledge and up to date education in infection control and anti-microbial stewardship.	PA Moderate	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	The care plans of one rest home, and two rest home residents did not contain sufficient detail to guide the staff in PEG care, nebuliser use, aspiration risk, suctioning, dealing with an abusive relative, tobacco, and alcohol use.	Ensure care plans are sufficiently detailed to guide staff in the safe care and management of resident’s needs and medical conditions	PA Moderate	In Progress
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.	i). Training sessions not evidenced as being held included abuse and neglect, advance directives, Code of rights, advocacy, infection control including standard precautions, outbreak management, waste management, falls prevention sessions privacy, complaints, resident welfare and medication education. ii). There was no evidence of staff attendance. iii). There was no evidence of the content of the training sessions that have been held. iv). The manager and clinical manager have not yet attend	i). Ensure all required training sessions are held according to schedule. ii). Ensure a record of attendance is maintained. iii). Ensure the content of the education sessions is held on file. iv). Ensure the manager and clinical nurse manager attend training in relation to managing an age care facility.	PA Low	In Progress
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 clinical nurse manager is aware of the need to review the infection control programme annually; however, this has not occurred.	Ensure the infection control programme is reviewed and reported on annually.	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). Positioning charts were not consistently completed for two residents requiring two hourly turns. ii). Neurological observations were not completed as per policy for six unwitnessed falls reviewed.	i). Ensure repositioning charts are completed as per policy. ii). Ensure neurological observations are completed as per policy	PA Moderate	In Progress
Service providers shall understand and comply with statutory and regulatory obligations in relation to essential notification reporting.	A Covid-19 outbreak in February/March 2024 was not notified to comply with notifiable disease requirements.	Ensure all outbreaks are notified as required.	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). Care plans had not been evidenced as reviewed six monthly in the four files reviewed of residents who had a care plan and had been in the service longer than six months. ii). Short term care plans had not been used for one hospital resident with a respiratory tract infection, and one with a wound.	i). Ensure all care plans are evidenced as being evaluated at least six monthly. ii). Ensure short term care plans are utilised for all short term needs as per policy.	PA Moderate	In Progress
Service providers shall establish environments that encourage collecting and sharing of high-quality Māori health information.	There was no evidence of collecting and sharing of Māori health information with staff.	Ensure Māori health information is shared with staff.	PA Low	In Progress
My complaint shall be addressed and resolved in accordance with the Code of Health and Disability Services Consumers’ Rights.	Four external complaint files were opened in 2023 (all notified by HDC), and these were not noted on the complaints register.	Ensure all complaints are documented on the complaints register	PA Low	In Progress
The decision to approve restraint for a person receiving services shall be made: (a) As a last resort, after all other interventions or de-escalation strategies have been tried or implemented; (b) After adequate time has been given for cultural assessment; (c) Following assessment, planning, and preparation, which includes available resources able to be put in place; (d) By the most appropriate health professional; (e) When the environment is appropriate and safe.	Two of seven residents utilising restraint did not have assessment, planning, risks and intervention needs of residents utilising restraint or related interventions documented in their care plan.	Ensure all interventions relating to restraint use are documented.	PA Moderate	Reporting Complete	17/03/2025
The frequency and extent of monitoring of people during restraint shall be determined by a registered health professional and implemented according to this determination.	Seven of seven residents using restraint did not have their restraint monitored consistently as per the timescales detailed in the restraint assessment.	Ensure restraint monitoring occurs according to the detailed frequencies.	PA Low	Reporting Complete	17/03/2025
A process shall be implemented to identify, record, and communicate people’s medicinerelated allergies or sensitivities and respond appropriately to adverse events.	Eight (two electronic, six paper) of the twelve medication charts reviewed did not have the allergy status completed.	Ensure all residents have their allergy status completed on the electronic medication chart	PA Moderate	Reporting Complete	17/03/2025

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: 24 July 2023

Audit type: Surveillance Audit

Audit date: 14 October 2021

Audit type: Certification Audit

Audit date: 15 October 2018