Premise details
- Address
- 57 Wai-iti Crescent Woburn Lower Hutt 5010
- Website
- http://www.psc.org.nz/enliven/rest-homes/woburn-home-lower-hutt/
- Total beds
- 100
- Service types
- Rest home care, Geriatric, Medical, Dementia care
Certification/licence details
- Certification/licence name
- Presbyterian Support Central - Woburn Home
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- Presbyterian Support Central
- Street address
- 3-5 George Street Thorndon Wellington 6011
- Postal address
- PO Box 12706 Thorndon Wellington 6144
- Website
- http://www.psc.org.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 |
|---|---|---|---|---|---|
| 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). Two of six files (rest home, dementia) had no signs, symptoms, or interventions to guide staff in managing a diabetic emergency; however, for both cases, progress notes contained details relating to these conditions, and staff interviewed could describe the required interventions in detail. (ii). In the same two files, the rest home resident did not have an activity plan detailed, and the dementia resident did not have a 24-hour activity plan detailed. | (i)-(ii)Ensure care plans are in place that accurately reflect resident need in sufficient detail to guide staff in the care of the resident. | PA Low | Reporting Complete | |
| All buildings, plant, and equipment comply with legislation. | i). Inconsistencies with hot water temperatures had been identified in 2020 and a corrective action plan written for action in November 2021. ii). There was no evidence of the taking or recording of the temperatures of the kitchenette fridges which contained milk and some food for residents. | i). Ensure corrective actions around hot water temperatures occur in a timely manner. ii). Ensure temperatures of the fridges in the kitchenettes are recorded at least daily. | PA Moderate | Reporting Complete | |
| The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group. | In the Court (dementia unit) there were five bathrooms with cracked vinyl coverings. This is an infection and falls risk. | To repair/replace surfaces that may be an infection risk or a falls risk. | PA Low | Reporting Complete | |
| Key components of service delivery shall be explicitly linked to the quality management system. | Resident meetings are scheduled three monthly and family meetings are scheduled six-monthly. However there has only been two meetings held in 2021 YTD (Residents in September and Families in March). Clinical meetings and staff meetings are scheduled monthly; but have been held irregularly. There were no meetings in February, March, and April 2021. There were no separate health and safety meetings as scheduled, however health and safety issues are discussed at the staff meetings. There are twice | Ensure that the meeting schedule is implemented | PA Low | Reporting Complete | |
| New service providers receive an orientation/induction programme that covers the essential components of the service provided. | Twelve personnel files were reviewed, two were new staff members who had not completed their orientation and they were not due. Two of the 10 remaining files did not have completed orientation record. | Ensure that staff orientation is completed, and completion records are maintained. | PA Low | Reporting Complete | |
| Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include: (a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk; (b) A process that addresses/treats the risks associated with service provision is developed and im | The health and safety officer has not completed health and safety representative training and there are no other staff with health and safety representative training. | Ensure that health and safety representation training is completed by the health and safety officer. | PA Low | Reporting Complete | |
| A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers. | Annual mandatory training has not been completed in 2020 and 2021. (ii) Three out of 11 staff members in the dementia unit have not completed the required dementia specific unit standards. (iii) Performance appraisals were not all undertaken in the last two years. Four of 11 staff files did not have an annual performance appraisal. Four staff members who had current 2021 appraisals also did not have one in 2020. | (i) Ensure that annual training plan is implemented. (ii) Ensure that staff who work in the dementia unit have undertaken dementia specific unit standards. (iii) Ensure that staff performance appraisals are completed annually. | PA Low | Reporting Complete | |
| Service providers shall ensure that there is a pandemic or infectious disease response plan in place, that it is tested at regular intervals, and that there are sufficient IP resources including personal protective equipment (PPE) available or readily accessible to support this plan if it is activated. | (i). Staff were observed to not adhere to the appropriate infection control practices. (ii). There was no evidence that ongoing infection control training/education included linen handling practice as part of daily cares. (iii). There was no re-audit of the infection control audit completed following non- compliance of infection control practices, including hand hygiene. (iv). Staff were conflicted in the management and disinfection of bedpans using the ArjoHuntleigh Ninjo sanitiser. | (i). Ensure education updates are delivered at defined intervals to verify ongoing compliance and competency. (ii). Ensure infection control education includes content around the management/handling of linen as part of daily cares. (iii). Ensure re-audits are completed for the effective monitoring of compliance of infection control practices. (iv). Ensure there are clearly documented guidelines for the disinfection of bedpans and the use of the sanitiser and follow up with staff education. | PA Moderate | Reporting Complete | |
| Service providers shall identify external and internal risks and opportunities, including potential inequities, and develop a plan to respond to them. | Actions outstanding raised and documented in meeting minutes have not always been signed off as addressed or completed. | Ensure that outstanding actions arising from meeting minutes are documented as addressed and signed off. | PA Low | Reporting Complete | |
| Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided. | Due to the change in the system, it was difficult to access certain parts of staff files to ascertain if the new clinical nurse manager, two new clinical coordinators and one newly employed HCA have completed orientation. | Ensure staff files are accessible to evidence completion of orientation records. | PA Low | Reporting Complete | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | (i). The staff appraisal schedule was not accessible. (ii). It was difficult to verify if staff performance appraisals that were due since September 2022 were completed. | (i) –(ii)Ensure the staff appraisal schedule is accessible to ensure ongoing monitoring. | PA Low | Reporting Complete | |
| Service providers shall ensure their health care and support workers have the skills, attitudes, qualifications, experience, and attributes for the services being delivered. | Three HCAs working in the dementia unit for more than 18 months are not yet enrolled to complete the relevant dementia standards as required. | Ensure all staff comply with the dementia education requirements in clause E4.5 f of the aged residential service agreement 2022-2023. | 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: Certification Audit
Audit date:
Audit type: Surveillance Audit
