Premise details
- Address
- 25 Ulyatt Road Meeanee Napier 4112
- Total beds
- 56
- Service types
- Geriatric, Medical, Dementia care, Rest home care
Certification/licence details
- Certification/licence name
- Bupa Care Services NZ Limited - Willowbank Care Home
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- Bupa Care Services NZ Limited
- Street address
- Level 2 109 Carlton Grove Road Newmarket Auckland 1023
- Postal address
- PO Box 113054 Newmarket Auckland 1149
- Website
- http://www.bupa.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 develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | (i). Audits are being completed as per the schedule; however, they are not signed off as being complete and corrective actions are not consistently documented when required. (ii). Meeting minutes have been inconsistently documented. Only one resident and family/whānau meeting occurred in 2024, quality meetings have not been held monthly as per schedule and the health and safety meetings were missed for February and March 2024 (iii). Meeting minutes, particularly the health and safety/ infection | (i). Ensure audits are signed off when complete and corrective actions are documented and implemented where required. (ii). Ensure meetings (as per the schedule) are documented as taken place. (iii). Ensure that meeting minutes are a reflection of the interaction of each individual meeting. | 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 rest home and one dementia level care resident did not have initial summary care plans completed within 48 hours of admission. (ii). Five (two rest home, two hospital and one dementia) of seven long term care plans were not completed within three weeks of admission. (iii). Four (two rest home, one dementia, one hospital) of six interRAI assessments were not completed within three weeks. (iv). Three (two dementia and one hospital) of five care plan evaluations were not completed as sch | (i)-(v). Ensure assessments, care plans and multi-disciplinary reviews are completed as scheduled. | PA Low | 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. | On the two days of audit the dementia unit lounge was not supervised on four separate occasions leaving residents unattended. | Ensure resident in the dementia unit are supervised. | PA Moderate | In Progress | |
| Service providers shall evaluate progress against quality outcomes. | Bupa Willowbank health and safety goals have not been documented as evaluated and progress towards goals is not documented. | Ensure that progress towards the stated goals is monitored including progress towards meeting goals. | PA Low | In Progress | |
| Meaningful activities shall be planned and facilitated to develop and enhance people’s strengths, skills, resources, and interests, and shall be responsive to their identity. | (i). There have not been consistent documented meaningful activities plan for dementia unit for the months prior to July 2024. (ii). No activities were held on the days of the audit in the dementia community. (iii). Residents and family/whānau interviewed did not report favourably with the level and variety of activities provided. | (i)-(iii). Ensure that meaningful activities shall be planned and facilitated to develop and enhance resident’s strengths, skills, resources, and interests. | PA Low | 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. | Training around Te Tiriti/ cultural safety, health equity, code of rights and privacy have not been provided as per schedule. | Ensure staff training is provided as per schedule. | PA Low | In Progress | |
| My services shall be provided in a manner that respects my dignity, privacy, confidentiality, and preferred level of interdependence. | It was noted from discussion with staff and from observation that the service uses communal underwear for residents (‘netti- knickers’). | Ensure that all residents are treated with respect and provided with personal clothing. | PA Low | In Progress | |
| A medication management system shall be implemented appropriate to the scope of the service. | (i). Weekly stock take for controlled drugs has not been completed consistently for the eight months reviewed (December 2023 – August 2024). (ii). Medication room temperature has not been consistently monitored for both medication rooms. (iii). Medication fridge temperature has not been consistently monitored for both fridges where medications are stored. (iv). There is no evidence that there is a system to consistently check for expired, medicines for deceased residents and unused medicines sto | (i). Ensure that stock check of controlled drugs is completed weekly. (ii-iii). Ensure that medication room and fridge temperature monitoring is completed as per policy. (iv). Ensure that there is a system in place to check for stock medicine. | 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 | (i). There are no detailed interventions to guide care staff in the delivery of care service for: (a). One dementia level care in relation to their risk of absconding. (b). One hospital level care resident in relation to oxygen management, shortness of breath and pain management. (c). One hospital level care resident in relation to falls minimisation and management strategies. (d). One rest home level care resident in relation to social activities; and (e). One of the couples in relation to t | (i)-(ii), Ensure care plans have detailed interventions to provide guidance to staff on care and are updated to reflect changes to resident needs and management plan. (iii). Ensure short term care plans are developed for short term needs as guided by the policy. | PA Low | 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. | Individual resident progress reviewed documented that one infection, one bruise and one cellulitis had not been reported to the incident and accident reporting system. | Ensure that all reportable events are reported though the electronic reporting system as per Bupa policy. | 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). Neurological observations have not been completed as per policy for three of six fall related incidents that required neurological observation to be completed. (ii). Blood glucose monitoring was not documented consistently for one rest home resident prior to insulin administration as evidence on the monitoring record. (iii). Pain assessments/monitoring were not completed for hospital level care resident prior to and following administration of ‘as required’ analgesia. | (i). Ensure neurological observations are completed as per policy. (ii)-(iii). Ensure monitoring records are completed as per policy and care plan requirements. | 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 | Residents’ progression towards meeting goals were not consistently documented in care plan evaluations for two of five resident care plans reviewed. | Ensure care plan evaluations provide evidence of resident progress towards goals. | PA Low | 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: Certification Audit
Audit date:
Audit type: Partial Provisional Audit
