Premise details
- Address
- 144 Queen Street West Levin 5510
- Total beds
- 57
- Service types
- Rest home care, Geriatric, Medical
Certification/licence details
- Certification/licence name
- The Ultimate Care Group Limited - Ultimate Care Madison
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- The Ultimate Care Group Limited
- Street address
- Level 2 111 Johnsonville Road Johnsonville Wellington 6037
- Postal address
- PO Box 425 Waterloo Quay Wellington 6140
- Website
- http://www.ultimatecare.co.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 |
|---|---|---|---|---|---|
| Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services. | (i). The roster does not always reflect full RN coverage during times of short notice absences. (ii). The CSM steps in as the RN to cover short notice absences with little time to support the quality programme. | (i). & (ii). Ensure recruitment is continued to increase availability of RNs to ensure full roster coverage and to relief the CSM to efficiently support the quality programme. | 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. | (i). Corrective actions related to internal audits are not always discussed at the quality and full staff meeting. (ii). Restraint committee meetings has not been commenced since April 2023. (iii). The infection control committee has not met quarterly as required since April 2023. | (i). Ensure corrective actions related to internal audits are discussed at quality and full staff meetings. (i)-(ii). Ensure that restraint meetings and IPC committee meetings occurs within the frequency required by Ultimate Care Group. | PA Low | Reporting Complete | |
| A medication management system shall be implemented appropriate to the scope of the service. | Daily medication room temperature monitoring readings have consistently been above 25 degrees Celsius between February 2024 to date with no evidence of any corrective actions taken to address the risk. | Ensure measures are put in place to ensure that room temperatures are maintained below 25 degrees Celsius at all times. | PA Moderate | 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 | (i). One hospital resident recently admitted with complex needs and deteriorating health did not have detailed interventions documented to provide staff with guidance on delivery of care. (ii). Interventions for an acute groin infection were not documented for one hospital resident. (iii). A short term care plan for another hospital level care resident with infection was delayed. | (i). – (iii). Ensure that there are detailed interventions documented as per policy to provide guidance to staff in the delivery of care needs. | PA Low | Reporting Complete | |
| 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). Repositioning monitoring chart has not been completed for one hospital level care resident with complex health needs and impaired skin integrity. (ii). Four of four wound care plans reviewed did not consistently have photos or wound measurements taken to assess and provide evidence of progress towards healing. | (i). Ensure monitoring charts are commenced as clinically indicated and completed. (ii). Ensure wound photos and measurements are completed. | 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). The initial care plan was not completed for one rest home resident and one hospital resident. (ii). Initial assessments were not completed within 24 hours for one rest home resident and one hospital resident. (iii). The initial interRAI assessment was not completed within three weeks of admission for one rest home resident. (iv). The long term care plan was not completed within three weeks of admission for one hospital resident and one rest home resident. (v). One rest home resident had | (i)-(v). Ensure that initial assessments, initial care plans, interRAI assessments, initial long term care plans and three monthly GP reviews are completed within the required timeframes. | 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: Certification Audit
Audit date:
Audit type: Surveillance Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Surveillance Audit
