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 |
|---|---|---|---|---|---|
| A process to measure achievement against the quality and risk management plan is implemented. | (i) Outcomes for corrective actions are not documented, inclusive of evaluations prior to sign off. (ii) Quality, health and safety, staff meetings do not fully inform staff of evaluations and outcomes. | (i) Outcomes and evaluations of corrective actions should be documented. (ii)) Quality, health and safety, staff meetings should clearly outline corrective actions and improvements. | PA Low | Reporting Complete | |
| The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code. | (i) Clinical aspects of complaints are not always identified to clinical management for follow up with clinical oversight. (ii) In respect of complaints involving human resource issues, there is no documentation of human resource policy being followed in the complaints register. (iii) Outcomes and rationale of the complaint are not always disclosed at staff meetings to educate and prevent recurrence. | (i) Clinical aspects of complaints need to have clinical management oversight as a part of the investigation and implementation of improvements. (ii) Human resource policy relating to employment code of conduct should be followed and notation of this process stated within the outcome of the complaint. (iii) Staff meetings should clearly outline the aspect of the complaint and the outcomes to educate staff and to prevent recurrence. | PA Moderate | Reporting Complete | |
| A process shall be implemented to identify, record, and communicate people’s medicinerelated allergies or sensitivities and respond appropriately to adverse events. | Recording of allergy and sensitivity status on the electronic medication chart is inconsistent. | Ensure allergy and sensitivity status is recorded on the electronic medication chart. | PA Moderate | Reporting Complete | |
| Service providers ensure competent health care and support workers manage medication including: receiving, storage, administration, monitoring, safe disposal, or returning to pharmacy. | Monitoring of medication room and medication fridge temperatures is inconsistent. | Ensure that monitoring of the medication room and medication fridge is conducted in line with UCG policy. | 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 were several shifts that did not have a RN on duty. | The provider is to ensure there are always sufficient RNs on duty to meet the agreed residential care services agreement with Te Whatu Ora and provide culturally and clinically safe services. | PA Moderate | 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 | Monitoring of neurological observations following all unwitnessed falls is inconsistent and is not in accordance with UCG policy or best practice. | Ensure that neurological observations are carried out in accordance with UCG policy and best practice. | 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 | Early warning signs and risks that may adversely affect a person’s wellbeing were not recorded. | Ensure that early warning signs and risks that may adversely affect a person’s wellbeing are recorded in sufficient detail to guide resident care in the event of a deterioration in their condition. | PA Moderate | 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: Surveillance Audit
Audit date:
Audit type: Certification Audit
