Premise details
- Address
- 3 McKellar Street Gore 9710
- Total beds
- 79
- Service types
- Physical, Dementia care, Rest home care, Geriatric, Medical
Certification/licence details
- Certification/licence name
- Bupa Care Services NZ Limited - Windsor Park Specialist Senior Care Centre
- 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 identify external and internal risks and opportunities, including potential inequities, and develop a plan to respond to them. | Corrective actions identified are not consistently signed off as complete. | Ensure corrective actions are signed off when complete. | PA Low | In Progress | |
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | (i)There are no quality meetings documented for 2023 and 2024; and no IPC meetings documented between April 2023 and March 2024. (ii) Staff meeting minutes occurred as planned; however, did not provide consistent evidence that staff are aware of review of quality goals, discussions around KPIs, benchmarking, corrective actions, internal audit results, restraint minimisation. | (i). Ensure all meetings occur as scheduled. (ii) Ensure meeting minutes evidence staff engagement/ discussions around quality data (including quality goals, infections, restraint, benchmarking), internal audit results and related corrective actions. | PA Moderate | In Progress | |
| A medication management system shall be implemented appropriate to the scope of the service. | (i). Room temperatures were not consistently documented in the hospital area. (ii). Controlled drug entries (two) did not evidence two staff signatures. | (i). Ensure temperatures of areas where medication is stored are consistently monitored as per policy. (ii). Ensure two staff check out controlled drug medication and sign as per legislative requirements and policy. | 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). Short term care plans were not commenced for recent changes in medication (commencement of insulin); same (rest home) resident’s care plan was not updated. (ii). Significant behaviours identified (dementia) did not have appropriate strategies/ de-escalation to manage the behaviours or antipsychotic management plan documented. (iii). One hospital level resident has no documented oxygen management plan including equipment management. | (i) – (iii) Ensure care plans are fully reflective of residents assessed needs. | PA Low | In Progress | |
| Service providers shall assist with training and support for people and service providers to maximise people and whānau receiving services participation in the service. | The service is certified to provide care for younger residents with physical disabilities and it unclear where the Principles of Enabling Good Lives fits into the content of the training calendar. | Ensure that the training /education are completed as per schedule or rescheduled to occur at a later stage. | 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: Surveillance Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Surveillance Audit
