Premise details
- Address
- 108 Thirteenth Avenue Tauranga South Tauranga 3112
- Total beds
- 88
- Service types
- Rest home care, Geriatric, Medical
Certification/licence details
- Certification/licence name
- The Ultimate Care Group Limited - Ultimate Care Oakland
- 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 evaluate progress against quality outcomes. | Internal clinical audits do not show evidence of documented corrective actions, resolution of issues, and closure. | Ensure internal clinical audits evidence documented corrective actions, resolution of issues and are closed out. | PA Moderate | In Progress | |
| A medication management system shall be implemented appropriate to the scope of the service. | The medication rooms were at the temperature on the days of audit; however, potentially there were no means to keep the rooms at 25 degrees or below in the heat of summer. | Ensure that the medication rooms remains at 25 degrees or below at all times. | PA Low | 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 | i). Initial assessments and care plans were documented using a tick system. There was no detail around interventions required. ii). One hospital resident with a current pressure injury and behaviours that challenge did not have care plans documented for the use of a bed cradle and management of behaviours. iii). One hospital resident had no plan around seizures documented. iv). One rest home resident had no interventions documented to manage pain. | Document interventions that describe care to be provided in the initial care plans. ii). – iv). Ensure detailed individualised interventions are documented in care plans to guide care. | PA Moderate | In Progress | |
| Service providers shall facilitate safe self-administration of medication where appropriate. | A competency to confirm that two residents were able to self-administer their own medication safely was not evidenced. | Ensure that any resident who self-administers medication has a competency signed to confirm safe storage and competency to take medications as prescribed. | 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). One resident (hospital level of care) did not have two hourly turns recorded as being completed. ii). Neurological observations are not completed as per policy in nine of nine sets of observations reviewed for residents who had a fall or who had hit their head | i). Ensure turning charts are completed as instructed in the care plans. ii). Ensure neurological observations are completed as per policy for residents who had a fall or who had hit their head | PA Low | In Progress | |
| Service providers shall ensure that the environment is clean and there are safe and effective cleaning processes appropriate to the size and scope of the health and disability service that shall include: (a) Methods, frequency, and materials used for cleaning processes; (b) Cleaning processes that are monitored for effectiveness and audit, and feedback on performance is provided to the cleaning team; (c) Access to designated areas for the safe and hygienic storage of cleaning equipment and chemi | The whole facility was not always kept clean e.g. some showers, external decks, windows, railings, and the medication rooms. | Complete a thorough clean of the facility initially with cleanliness then maintained to a high standard on a daily basis. | PA Moderate | 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. | There were no action plans in the business plan to support implementation, monitoring, review and evaluation of the stated objectives. | Ensure action plans against objectives in the business plan are documented with regular review and evaluation of the stated objectives. | PA Low | In Progress | |
| Service providers shall ensure there are implemented fire safety and emergency management policies and procedures identifying and minimising related risk. | Four residents were observed smoking outside on an outdoor deck or in their room with smoke noted in an adjacent non-smoking resident’s room and hallways. | Review site smoking policies and implementation to ensure risks related to fire safety and the needs of other residents and staff are identified and minimised. | 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
