Premise details
- Address
- 227 Mount Eden Road Mount Eden Auckland 1024
- Total beds
- 51
- Service types
- Rest home care
Certification/licence details
- Certification/licence name
- Victoria Mt Eden Limited - Wesley Home and Care
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 12 months
Provider details
- Provider name
- Victoria Mt Eden Limited
- Street address
- Wesley 227 Mount Eden Road Mount Eden Auckland 1024
- Postal address
- 227 Mount Eden Road Mount Eden Auckland 1024
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 improve health equity through critical analysis of organisational practices. | Wesley does not improve health equity through critical analysis of organisational practices. | Provide evidence that a process has been implemented to improve health equity through critical analysis of organisational practices. | PA Moderate | In Progress | |
| My service provider shall ensure cultural safety for Pacific peoples and that their worldviews, cultural, and spiritual beliefs are embraced. | The service has not embedded or enacted cultural safety for Pasifika in the service. There were no effective policies and procedures in place outlining how the service will support Pasifika people. Staff and volunteer carers were not able to describe Pasifika worldviews, or cultural and spiritual beliefs related to Pacific peoples. | Ensure there are policies and procedures in place related to culturally safe and equitable care for Pasifika. Policy and procedures are to be written in conjunction with Pacific peoples. Provide evidence that staff and volunteer carers have had education/training to enable them to understand Pasifika worldviews, and cultural and spiritual beliefs related to Pacific peoples. | UA Low | In Progress | |
| My service provider shall focus on achieving equity and efficient provision of health and disability services for Pacific peoples. | There are no policies/documentation in place to describe how the service will achieve equity and efficient provision of health and disability services for Pasifika. Staff and volunteer carers do not understand their obligations to health equity for Pasifika. | Ensure policies/documentation describe how the service will achieve equity and efficient provision of health and disability services for Pasifika. Provide evidence that the staff and volunteer carers have had education/training to enable them to understand their obligations to health equity for Pasifika. | UA Low | In Progress | |
| My service provider shall design a Pacific plan in partnership with Pacific communities underpinned by Pacific voices and Pacific models of care. | The organisation does not have an appropriate model of care documented for Pasifika to support service delivery for Pasifika. | Provide evidence that a model of care appropriate for Pasifika has been documented to support service delivery for Pasifika. | UA Low | In Progress | |
| My service provider shall actively recruit, train, and retain a holistic Pacific health and wellbeing workforce that is responsive to the Pacific population’s health and disability needs. This will include Pacific peoples in leadership and training roles. | There are no recruitment strategies in place to recruit and retain Pasifika in the workforce and no documentation in relation to how this will be addressed by the service in any policy or strategic document. | Provide evidence that recruitment strategies to recruit and retain Pasifika in the workforce and in leadership and training positions are in place. These are to be documented in policy and/or strategic documentation. | UA Low | In Progress | |
| My service provider shall work in partnership with Pacific communities and organisations, within and beyond the health and disability sector, to enable better planning, support, interventions, research, and evaluation of the health and wellbeing of Pacific peoples to improve outcomes. | The service has not developed any partnerships with Pasifika communities or organisations to enable service integration, planning, or support for Pasifika with a view to improving health and wellbeing outcomes for Pasifika. | Provide evidence that partnerships with Pasifika communities or organisations have been established to enable better service integration, planning, and support for Pasifika, with a view to improving health and wellbeing outcomes for Pasifika. | UA Low | In Progress | |
| Te reo Māori and tikanga Māori shall be actively promoted throughout organisations and incorporated through all their activities. | Te reo Māori and tikanga Māori are not actively promoted throughout the organisation, nor incorporated through all their activities. | Provide evidence that te reo Māori and tikanga Māori are being actively promoted throughout the organisation and incorporated through all their activities. | 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. | There is no IP programme in place specific to Wesley. The programme in place has not been approved by the governing body, is not linked to a quality and risk programme, and is not reviewed and reported on annually. | Ensure the IP programme in place at Wesley is specific to Wesley, that the programme has been approved by the governing body and linked to a quality and risk programme, and that the programme is reviewed and reported on annually. | PA Moderate | In Progress | |
| Service providers shall develop written IP policies with input from suitably qualified personnel, which comply with relevant legislation and accepted best practice. The suite of policies shall include: (a) Hand hygiene and standard precautions; (b) Aseptic technique; (c) Transmission-based precautions; (d) Prevention of sharps injuries; (e) Prevention and management of communicable infectious diseases in service providers and users; (f) Management of current and emerging multi-drug-resistant org | The service provider has not developed written IP policies with input from suitably qualified personnel, which comply with relevant legislation and accepted best practice. | Provide evidence that the service provider has developed written IP policies with input from suitably qualified personnel, which comply with relevant legislation and accepted best practice. | PA Moderate | In Progress | |
| Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided. | There is no evidence to show that people working in the service (staff and volunteer carers) have completed an orientation programme that prepares them for all the roles they are performing in the service. | Provide evidence that an orientation programme is being delivered that prepares people working in the service for any role they are performing in the service. | PA Moderate | In Progress | |
| Service providers shall ensure their health care and support workers can deliver highquality health care for Māori. | There are no policies, procedures or processes in place to ensure staff and carers can deliver high-quality health care for Māori. | Establish policies, procedures and processes to assist staff and carers to so that they can deliver high-quality health care for Māori, if Māori were to enter the service. | PA Low | In Progress | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | Not all people working in the service have the opportunity to discuss and review performance at defined intervals. | Ensure all people working in the service have the opportunity to discuss and review performance at defined intervals. | PA Moderate | In Progress | |
| Service providers shall maintain quality records that comply with the relevant legislation, health information standards, and professional guidelines, including in terms of privacy. | Wesley has no policies and procedures in place to describe how it will comply with relevant legislation, health information standards, privacy, or professional guidelines. | Provide policies and procedures that describe how Wesley will comply with relevant legislation, health information standards, privacy, and professional guidelines. | UA Moderate | In Progress | |
| Results of surveillance and recommendations to improve performance where necessary shall be identified, documented, and reported back to the governance body and shared with relevant people in a timely manner. | The processes for analysing the results of surveillance of HAIs is not in place. Information collected is not collated to identify any trends, possible causative factors or required actions to mitigate these. Results are not reported to staff/volunteer carers. | Provide evidence that processes for analysing the results of surveillance of HAIs is in place, that the information is collated to identify any trends, possible causative factors and required actions to mitigate these. Provide evidence that the results of surveillance activities are reported to staff/volunteer carers. | PA Moderate | In Progress | |
| The Code of Health and Disability Services Consumers’ Rights and the complaints process shall work equitably for Māori. | There were no policies and procedures related to the management of complaints at Wesley and no documentation to advise how complaints from Māori (if they were admitted to the service) would be managed to support equity. The services had no tikanga guidelines to support the complaints process for Māori, or relationships to support Māori in the complaints process if they were to be admitted to the service. | Provide evidence that policies and procedures related to the management of complaints at Wesley document how complaints from Māori (if they were admitted to the service) would be managed to support equity. This includes tikanga guidelines to support the complaints process for Māori, and ensuring appropriate support would be available for them. | UA Low | In Progress | |
| Governance bodies shall have demonstrated expertise in Te Tiriti, health equity, and cultural safety as core competencies. | The directors cannot demonstrate expertise in health equity, principles and responsibilities in relation to Te Tiriti o Waitangi, or cultural safety. | Ensure the directors complete relevant education and training to develop knowledge and expertise in relation to Te Tiriti o Waitangi, health equity and cultural safety. | UA Moderate | In Progress | |
| There shall be a clinical governance structure in place that is appropriate to the size and complexity of the service provision. | Wesley has no clinical governance structures in place, clinical risks are not linked to a quality and risk system. | Provide evidence that clinical governance structures have been instituted so that the governance group has oversight of clinical risks as part of a quality and risk systems. | PA Moderate | In Progress | |
| My service provider shall embed and enact Te Tiriti o Waitangi within all its work, recognising Māori, and supporting Māori in their aspirations, whatever they are (that is, recognising mana motuhake). | The service has not embedded or enacted Te Tiriti o Waitangi within its service, recognising the Crown’s partnership with Māori in the health sector. There are no effective policies and procedures in place outlining how the service will support Māori aspirations in the service should Māori be admitted. Staff and volunteer carers do not understand their obligations to Te Tiriti o Waitangi, or to Māori as tāngata whenua, or how to embed Te Tiriti of Waitangi principles into their practice. | Ensure there are policies and procedures in place related to culturally safe care for Māori, recognising Te Tiriti o Waitangi and support for Māori aspirations (including mana motuhake). Policy and procedures are to be written in conjunction with Māori. Provide evidence that further education/training has taken place to ensure staff and volunteer carers understand their obligations in relation to Te Tiriti o Waitangi, and for Māori as tāngata whenua, and how to embed Te Tiriti of Waitangi princi | UA Low | In Progress | |
| My service provider shall actively recruit and retain a Māori health workforce across all organisational roles. | There are no recruitment strategies in place to recruit and retain Māori in the workforce and no documentation in relation to how this will be addressed by the service in any policy or strategic document. | Provide evidence that recruitment strategies to recruit and retain Māori in the workforce are in place and that these are documented in policy and/or strategic documentation. | UA Low | In Progress | |
| To facilitate equity approaches, my service provider shall be Māori centred. | The service is not Māori-centred, nor are there any policies or documentation in place that promote equity for Māori. | Provide evidence that the service is Māori-centred, with policies and documentation that show how the service will promote equity for Māori. | UA Low | In Progress | |
| My service provider shall work in partnership with iwi and Māori organisations within and beyond the health sector to allow for better service integration, planning, and support for Māori. | The service has not developed any partnerships with iwi or Māori community organisations to enable better service integration, planning, and support for Māori. | Provide evidence that partnerships with iwi or Māori community organisations have been established to enable better service integration, planning, and support for Māori. | UA Low | In Progress | |
| The governance body shall identify the IP and AMS programmes as integral to service providers’ strategic plans (or equivalent) to improve quality and ensure the safety of people receiving services and health care and support workers. | Infection prevention and AMS programmes have not been identified as integral to the services being provided at Wesley. There are no strategic plans (or equivalent) which would allow such documentation. | Ensure IP and AMS are identified as integral to strategic plans (or equivalent) when these are put into place. | PA Moderate | In Progress | |
| There shall be a formally agreed mechanism for accessing appropriate IP and AMS expertise that assists with defining the strategic direction and provides advice to the governance body. | There is no formally agreed mechanism for accessing appropriate IP and AMS expertise that assists with defining the strategic direction of the organisation. | Institute a formally agreed mechanism for accessing appropriate IP and AMS expertise that assists with defining the strategic direction of the organisation. Put a strategic plan (or equivalent) in place that includes IP and AMS. | 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. | There is no implemented system to determine, develop and record the competencies of all people delivering services to residents to meet the needs of people equitably. | Implement systems to determine, develop and record the competencies of staff to meet the needs of residents equitably. Ensure that all staff are regularly provided with opportunities to learn and understand how to meet the needs of people equitably, and that competency records for all people working in the service are maintained. | PA Moderate | In Progress | |
| Governance bodies shall demonstrate commitment toward eliminating restraint. | The governance group is unable to demonstrate commitment toward eliminating restraint. | Provide evidence that the governance group has a commitment to eliminate restraint through the provision of a restraint elimination programme, policy and procedure to guide the programme, and a commitment in strategic (or equivalent) documentation. | PA Moderate | In Progress | |
| Governance bodies shall ensure service providers deliver services that improve outcomes and achieve equity for Māori. | The service provider is unable to demonstrate how they will improve outcomes and achieve equity for Māori. | Establish methods for ensuring that services improve outcomes and achieve equity for Māori. | UA Low | 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. | While there is a plan in place to facilitate and record learning, the programme is not well attended and not all the subject matter is available to support staff/volunteer carers for the benefit of residents. Not all staff/volunteer carers have attended at least eight hours of professional development. | Provide evidence that people working in the service have attended at least eight hours of professional development annually and that the programme being delivered is complete and meets the requirements of Ngā Paerewa and the facility’s contract with Te Whatu Ora. | PA Moderate | In Progress | |
| Service providers demonstrate routine analysis to show entry and decline rates. This must include specific data for entry and decline rates for Māori. | There is no process in place to demonstrate analysis of entry and decline rates for residents, including residents who identify as Māori. | A process to demonstrate collection and analysis of entry and decline rates for residents, including residents who identify as Māori, is to be implemented. | PA Low | In Progress | |
| Service providers shall have a documented AMS programme that sets out to optimise antimicrobial use and minimising harm. This shall be: (a) Appropriate for the size, scope, and complexity of the service; (b) Approved by the governance body; (c) Developed using evidence-based antimicrobial prescribing guidance and expertise (which includes restrictions and approval processes where necessary and access to laboratory diagnostic testing reports). | Wesley does not have a documented AMS programme in place that sets out to optimise antimicrobial use, minimise harm, that is relevant to the service and has been approved by the governance group. | Provide evidence that Wesley has a documented AMS programme in place that sets out to optimise antimicrobial use, minimise harm and that is relevant to the service. Provide evidence that the AMS programme has been approved by the governance group. | PA Moderate | In Progress | |
| Prior to a Māori individual and whānau entry, service providers shall: (a) Develop meaningful partnerships with Māori communities and organisations to benefit Māori individuals and whānau; (b) Work with Māori health practitioners, traditional Māori healers, and organisations to benefit Māori individuals and whānau. | No meaningful partnerships with Māori communities and organisations to benefit Māori individuals and whānau have been developed, these include relationships with Māori health practitioners, traditional Māori healers, and organisations to benefit Māori individuals and whānau. | Develop meaningful partnerships with Māori communities and organisations to benefit Māori individuals, including relationships with Māori health practitioners, traditional Māori healers, and organisations to benefit Māori individuals and whānau. | PA Low | In Progress | |
| Service providers shall conduct comprehensive reviews at least six-monthly of all restraint practices used by the service, including: (a) That a human rights-based approach underpins the review process; (b) The extent of restraint, the types of restraint being used, and any trends; (c) Mitigating and managing the risk to people and health care and support workers; (d) Progress towards eliminating restraint and development of alternatives to using restraint; (e) Adverse outcomes; (f) Compliance w | Six-monthly review of restraint cannot be verified as it has only just become due. | Ensure six-monthly review of restraint is undertaken in September 2024. | PA Low | In Progress | |
| Service providers shall have policies and guidelines in place, appropriate to the size, scope, and complexity of the service, which will comply with evidence-informed practice. | Wesley does not have documented policies and procedures in place in relation to AMS management and which will comply with evidence-informed practice. | Provide evidence that Wesley has documented policies and procedures in place in relation to AMS management which comply with evidence-informed practice. | PA Moderate | In Progress | |
| Service providers shall establish environments that encourage collecting and sharing of high-quality Māori health information. | There are no methods yet established for the collection and sharing of high-quality Māori health information. Staff/volunteer carers have had little opportunity to participate in learning opportunities that provide them with the most recent literature on Māori health outcomes and disparities, Māori models of care, and health equity. | Provide records to show that people working in the service have participated in learning opportunities that provide them with the most recent literature on Māori health outcomes and disparities, Māori models of care, and health equity. | UA Low | In Progress | |
| Service providers shall ensure safe and appropriate storage and disposal of waste and infectious or hazardous substances that complies with current legislation and local authority requirements. This shall be reflected in a written policy. | There are no policies and procedures in place to guide staff on the appropriate storage and disposal of waste and infectious or hazardous substances as it applied to the law and local authority requirements. | Provide evidence that policies and procedures are in place to guide staff on the appropriate storage and disposal of waste and infectious or hazardous substances as it applied to the law and local authority requirements. | PA Moderate | In Progress | |
| Executive leaders shall report restraint used at defined intervals and aggregated restraint data, including the type and frequency of restraint, to governance bodies. Data analysis shall support the implementation of an agreed strategy to ensure the health and safety of people and health care and support workers. | Restraint is reported at defined intervals, but restraint data, including the type and frequency of restraint, is not aggregated or trended over time. Data analysis does not support the elimination of restraint, or the implementation of an agreed strategy to ensure the health and safety of residents who are using restraint or staff/volunteer carers. | Provide evidence that restraint data, including the type and frequency of restraint, is aggregated and trended over time. Data analysis is to be used to support the implementation of an agreed strategy to eliminate restraint, and where this is not possible, to ensure the health and safety of residents who are using restraint and staff/volunteer carers. | PA Moderate | In Progress | |
| Governance bodies shall support people receiving services and whānau to participate in the planning, implementation, monitoring, and evaluation of service delivery. | Evidence of governance commitment to resident and whānau participation could not be demonstrated. | Ensure that people receiving services, and their whanau, are given opportunities to participate in the planning, implementation, monitoring and evaluation of service delivery, and the vehicles to allow this, are written in a policy approved by governance. | PA Moderate | In Progress | |
| My service provider shall prioritise a strengths-based and holistic model ensuring wellbeing outcomes for Māori. | A strengths-based and holistic model ensuring wellbeing outcomes for Māori was not in place. | Ensure that a strengths-based and holistic model ensuring wellbeing outcomes for Māori is in place. | PA Low | In Progress | |
| Service providers shall invest in the development of organisational and health care and support worker health equity expertise. | Wesley has not invested in the development of health equity expertise for staff/volunteer carers. | Provide evidence that directors and people working in the service have had access to, and have developed an understanding of, health equity. | PA Low | In Progress | |
| The nutritional value of menus shall be reviewed by appropriately qualified personnel such as dietitians. | The nutritional value of menus has not been reviewed by an appropriately qualified person, such as a dietitian. There are no approved recipes for use for food preparation. | Provide evidence that the nutritional value of menus has been reviewed by an appropriately qualified person, such as a dietitian, and that there are approved recipes available to be followed for food preparation. | UA Moderate | In Progress | |
| Service providers shall implement policies and procedures underpinned by best practice that shall include: (a) The process of holistic assessment of the person’s care or support plan. The policy or procedure shall inform the delivery of services to avoid the use of restraint; (b) The process of approval and review of de-escalation methods, the types of restraint used, and the duration of restraint used by the service provider; (c) Restraint elimination and use of alternative interventions shall | There are no policies and procedures to guide restraint use at Wesley. | Policy and procedure, underpinned by best practice, is to be sourced and implemented at Wesley to guide practice. | PA Moderate | In Progress | |
| Governance bodies shall have meaningful Māori representation on relevant organisational boards, and these representatives shall have substantive input into organisational operational policies. | The directors have not yet established links or relationships with local iwi, nor have they determined how they will meet this requirement. | Ensure there is meaningful Māori representation and input into organisational policies and processes. | UA Moderate | In Progress | |
| 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 | Laundry services are unsafe, there is no clear separation and demarcation of clean/dirty laundry areas, there is no signage to indicate an entry and exit door. The space is not secured for the safe storage of chemicals. | Institute written policies to guide safe laundry services. Ensure that there is a clear separation and demarcation of clean and dirty areas in the laundry area, and that entry/exit doors are appropriately labelled. Ensure access into the laundry is secure and allows for the safe storage of laundry chemicals. | PA Moderate | In Progress | |
| Service providers shall ensure that the IP role has – or IP personnel have – oversight of the facility testing and monitoring programme for the built environment. | There is no documentation to guide the IPCC in their responsibilities, including the responsibility for facility testing and monitoring of the built environment. | Ensure the IPCC has a current job description that describes their responsibilities for facility testing and monitoring the built environment. | PA Low | In Progress | |
| Service providers adopt a holistic approach to menu development that ensures nutritional value, respecting and supporting cultural beliefs, values, and protocols around food. Māori and whānau shall have menu options culturally specific to te ao Māori. | The service has no menu options culturally specific to te ao Māori. | Institute menu options culturally specific to te ao Māori. | PA Low | In Progress | |
| Service providers shall follow the appropriate best practice tikanga guidelines in relation to consent. | Most staff and volunteer carers did not understand the concept of tikanga in relation to consent. | Ensure the education/training programme includes tikanga, including tikanga in relation to consent, and provide evidence that people working in the service have completed the education/training. | PA Low | In Progress | |
| IP personnel and committees shall participate in partnership with Māori for the protection of culturally safe practice in IP, and thus acknowledge the spirit of Te Tiriti. | There are no partnerships with Māori for the protection of culturally safe practice in IP, to acknowledge the spirit of Te Tiriti o Waitangi. | Institute partnerships with Māori for the protection of culturally safe practice in IP, to acknowledge the spirit of Te Tiriti o Waitangi. | PA Low | In Progress | |
| Health care and support workers shall receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures. | There were no processes in place to record safety checking of fire extinguishers. | Provide evidence that there is a process in place to check fire extinguishers annually. | PA Moderate | In Progress | |
| Service providers shall ensure the skills and knowledge required of each position are identified and the outcomes, accountability, responsibilities, authority, and functions to be achieved in each position are documented. | Wesley does not ensure the skills and knowledge required of each position are identified, and the outcomes, accountability, responsibilities, authority, and functions to be achieved in each position are not documented. Not all staff, and no volunteer carers, have position descriptions relevant to the work they are performing. | Provide evidence that the skills and knowledge required of each position are identified and the outcomes, accountability, responsibilities, authority, and functions to be achieved in each position are documented. Provide evidence that all people working in the service have position descriptions relevant to the work they are performing. | PA High | In Progress | |
| My right to make a complaint shall be understood, respected, and upheld by my service provider. | The right to make a complaint is not understood, respected or upheld by the service provider. There is no free access to complaints information and staff and volunteer carers were unsure of the process to respond to the complaint despite education being provided in 2024. | Establish an appropriate complaints management process and provide evidence that this has been embedded in the service. Provide evidence that staff and volunteer carers have had further education in the complaints process and know what to do in the event that someone wishes to make a complaint. | UA High | In Progress | |
| I shall be informed about and have easy access to a fair and responsive complaints process that is sensitive to, and respects, my values and beliefs. | There are no processes in place to allow residents, their whānau, or any other person to easily make a complaint. Where a complaint has been made, it has not been documented. Information on support for people wishing to make a complaint is not available in the facility. Staff and volunteer carers were unsure of the processes to be used for managing a complaint. | Provide evidence that there is a process in place to disseminate complaints information to residents and their whānau, including support for the complaints process. Provide evidence that complaints information, forms and support information is readily available in the facility and that complaints are documented. Provide evidence that the staff have had further education/training in the complaints process and know what to do in the event that someone wishes to make a complaint. | UA High | In Progress | |
| My complaint shall be addressed and resolved in accordance with the Code of Health and Disability Services Consumers’ Rights. | There is no documentation available to verify that complaints will be managed in accordance with the Code of Health and Disability Services Consumers’ Rights. There are no policies and procedures in place to describe to steps to be taken for a complaint, and no brochures available in the facility on the Code, or the HDC Advocacy Service. The facility manager did not understand the complaints/advocacy processes. | Provide evidence that policies and procedures related to complaints management meet the requirements of the Code of Health and Disability Services Consumers’ Rights, and that the facility manager has been educated on responsibilities in relation to the complaints process. Provide evidence that information on the Code and the HDC Advocacy service are readily available in the facility. | UA High | In Progress | |
| I am informed of the findings of my complaint. | There are no processes in place to ensure residents are formally advised of the outcome of complaints. | Provide evidence that there are processes in place to ensure residents are formally advised of the outcome of complaints. | UA High | In Progress | |
| Governance bodies shall ensure compliance with legislative, contractual, and regulatory requirements with demonstrated commitment to international conventions ratified by the New Zealand government. | There was no programme to ensure that policies and procedure are in place and implemented at the facility that describe compliance with legislative, contractual and regulatory requirements, including policies and procedures required under the provider’s contract with Te Whatu Ora. | Provide evidence that policies and procedures are in place and implemented that are fit for purpose, describe compliance with legislative, contractual, and regulatory requirements, and meet the provider’s contract with Te Whatu Ora. | UA High | 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. | The service’s purpose, values, scope, direction, performance and goals are not clearly identified or documented, nor had these been monitored, reviewed or evaluated. | Provide evidence that the service’s purpose, values, scope, direction, performance and goals are clearly identified and documented, and that there is a process in place to monitor, review and evaluated these, and the structure of organisation, at defined intervals. | UA High | In Progress | |
| Service providers shall ensure the quality and risk management system has executive commitment and demonstrates participation by the workforce and people using the service. | The organisation does not have a planned quality and risk management system in place that has executive commitment and demonstrates participation by the workforce and people using the service. | Establish a planned quality and risk management system that has executive commitment and demonstrates participation by the workforce and people using the service. | PA High | In Progress | |
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | The service provider has not developed and implemented a quality management framework using a risk-based approach to improve service delivery and care. | Provide evidence that a quality management framework has been developed and implemented and that it uses a risk-based approach to improve service delivery and care. | UA High | In Progress | |
| Service providers shall evaluate progress against quality outcomes. | There are no processes in place for the service to evaluate progress against quality outcomes and manage a corrective action process. | Establish processes to allow the service to evaluate progress against quality outcomes and manage a corrective action process. | UA High | In Progress | |
| Service providers shall identify external and internal risks and opportunities, including potential inequities, and develop a plan to respond to them. | Wesley does not have a framework or policies in place to identify external and internal risks and opportunities (including potential inequities), nor does it have a plan to respond to them. | Provide evidence that a framework and policies have been established to identify external and internal risks and opportunities (including potential inequities), and the service will respond to and manage them. | UA High | In Progress | |
| Service providers shall follow the National Adverse Event Reporting Policy for internal and external reporting (where required) to reduce preventable harm by supporting systems learnings. | Not all residents who had an unwitnessed fall or a fall with an observed ‘head blow’ had neurological observations completed. There is no policy or procedure outlining a process for the guidance of staff and carers. | Provide evidence that there is a process in place to ensure that all residents who have an unwitnessed fall, or a fall with an observed ‘head blow’, have neurological observations completed. The process should be outlined in a policy or procedure document for the guidance of staff and carers. | PA High | Reporting Complete | |
| Governance bodies shall evidence leadership and commitment to the quality and risk management system. | There is no overarching quality and risk plan that has been approved by the governing body. The facility manager did not understand the concepts of risk management. | Establish an overarching quality and risk plan that has been approved by the governing body and is relevant for the service provided. Ensure that the facility manager understands the concepts of risk management and how to apply its principles into practice. | UA High | In Progress | |
| Governance bodies shall appoint a suitably qualified or experienced person to manage the service provider with authority, accountability, and responsibility for service provision. | The facility manager needs to develop skills and knowledge related to management of a residential aged care service, including the contractual, legislative and regulatory requirements for the role. | Provide evidence that the facility manager fully understands all the contractual, legislative and regulatory requirements for managing a residential aged care facility. | UA High | In Progress | |
| Service providers shall develop and implement policies and procedures in accordance with good employment practice and meet the requirements of legislation. | There are no policies and procedures implemented in the facility to guide good employment practices. Not all of the staff working in the facility on the roster are employed as required by law using best practice guidelines. | Provide evidence that there are policies and procedures implemented in the facility to guide good employment practices, and that all of the staff working in the facility on the roster are employed as required by the law, using best practice guidelines. | UA High | 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 are insufficient health care and support workers on duty at all times to provide culturally and clinically safe services commensurate to the needs and number of residents on site. Not all people who are integral to the roster are employed by the service. There are insufficient clinical manager/registered nurse hours allocated to the facility given the number of residents in the facility and the clinical manager’s responsibility for another site. | Provide evidence that there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services commensurate to the needs and number of residents on site, and the geography of the facility. Provide evidence that all staff who are integral to the roster are employed by the service. Provide evidence that there are sufficient clinical manager or registered nurse hours allocated to the facility ensure safe services. | PA High | In Progress | |
| Service providers shall ensure their health care and support workers have the skills, attitudes, qualifications, experience, and attributes for the services being delivered. | Not all people working to manage the health care and support for residents have had their skills, attitudes, qualifications, experience and attributes for the service assessed. Volunteers are not employed and have no records. | Provide evidence that all people working to manage the health care and support for residents are employed by the service and have had their skills, attitudes, qualifications, experience and attributes for the service assessed. | PA High | In Progress |
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: Partial Provisional Audit
