Aberleigh Rest Home
Profile & contact details
| Premises name | Aberleigh Rest Home |
|---|---|
| Address | 17 McCallum Street Springlands Blenheim 7201 |
| Total beds | 62 |
| Service types | Rest home care, Psychogeriatric, Geriatric, Medical, Dementia care |
| Certification/licence name | Aberleigh Rest Home Limited - Aberleigh Rest Home |
|---|---|
| Current auditor | Health and Disability Auditing New Zealand Limited |
| End date of current certificate/licence | 26 August 2025 |
| Certification period | 36 months |
| Provider name | Aberleigh Rest Home Limited |
|---|---|
| Street address | 34 Averill Street Richmond Christchurch 8013 |
| Post address |
Progress on issues from the last audit
What’s on this page?
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.
Details of corrective actions
Date of last audit: 15 June 2022
| Outcome required | Found at audit | Action required | Risk rating | Action status | Date action reported complete |
|---|---|---|---|---|---|
| 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) Long-term care plans were developed for the eight files reviewed. However, four of these were not informed by an initial interRAI assessment (one psychogeriatric and three hospital) and on one occasion, a six-monthly interRAI assessment was also incomplete for one psychogeriatric resident. ii) Care plan evaluations have not occurred within required timeframes for three hospital level files. iii) There were no specific interventions for weight management documented for one rest home and one… (this text has been trimmed due to space limits). | i) Ensure that initial interRAI are completed within 21 days of admission and then at six-monthly intervals. ii) Ensure care plan evaluations occur at least six-monthly. iii) Ensure there are specific interventions for identified issues including those triggered in the interRAI assessment. | PA Low | Reporting Complete | 28/09/2023 |
| 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 is an RN based in the psychogeriatric unit on morning and afternoon shifts and one RN on night shift based in the psychogeriatric unit who provides cover for the hospital, rest home and dementia unit. However, this does not meet the staffing requirement for the facility on night shift as there over 50 residents. The service has been recruiting for a second RN on night shift, however the vacancy had not been filled at the time of audit. | Ensure the RN staffing meets the ARHSS contract between the hours of 10pm and 7am where there are over 50 residents in the facility. | PA Moderate | Reporting Complete | 03/01/2024 |
| Buildings, plant, and equipment shall be fit for purpose, and comply with legislation relevant to the health and disability service being provided. The environment is inclusive of peoples’ cultures and supports cultural practices. | One oxygen concentrator and one suctioning equipment have not been tested since 2022. | Ensure all equipment is included in the annual testing and calibration schedule. | 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) Timeframes related to contractual requirements were not always met in the eight the files reviewed and include: a) Four residents (one rest home, two PG, one hospital) did not have a care plan documented within 21 days of admission or thereafter; b) Two PG residents had no initial interRAI completed. They were admitted in August 2023 and still do not have an interRAI. One resident from the dementia unit was overdue for an interRAI reassessment; c) One resident in the dementia unit had no int… (this text has been trimmed due to space limits). | (i). Ensure assessment and care planning processes align with any contractual requirements and include individual goal setting. (ii) Ensure documentation reflects evidence of whānau/resident input. | PA Moderate | 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. | (i) There is a registered nurse based across the hospital/rest home units in the morning and afternoon shifts; however, there is no RN on night duties at the facility from 11pm to 7am. The service does not meet the staffing requirements of the Age-Related Residential Care Services Agreement (ARCC) D17.4 i. The clinical manager is on call seven days a week to manage clinical emergencies. In the psychogeriatric unit, there is one RN for two morning shifts a week, and the clinical manager is roster… (this text has been trimmed due to space limits). | (i) and (ii) Ensure 24/7 RN cover to meet the requirements of the ARRC and ARHSS agreements. (ii). Ensure sufficient interRAI qualified RNs to undertake interRAI assessments in a timely manner. | PA High | In Progress | |
| Service providers shall evaluate progress against quality outcomes. | A review of clinical file internal audits identified that audits completed (October 2023 and November 2023) had an outcome of 72% and 52%. Corrective actions were not established where shortfalls were identified around care plan interventions and assessments. | Ensure that corrective actions required from the clinical file audits are developed and actioned. | PA Moderate | In Progress | |
| A medication management system shall be implemented appropriate to the scope of the service. | (i) A resident prescribed anticoagulant medication necessitates a monthly INR test, but the test has not been conducted within the past 18 days, which exceeds the recommended monthly interval. This was alerted by the auditors. (ii). A resident who has received more than 40 doses of quetiapine since being admitted to the service in October 2023. This resident also does not have a documented care plan in place. The initial medical admission was conducted by the GP, and the clinical manager report… (this text has been trimmed due to space limits). | (i). Ensure that medicines are managed as prescribed by the GP and follow up tests to manage dosage is undertaken. (ii)-(iii) Conduct a thorough review of current practices related to medication management. Ensure that PRN medication administration is monitored by the RNs and GP, and input regarding use of antipsychotics drugs are obtained and documented. Ensure that oversight and communication with the GP and OPMH team is documented. (iv) Ensure a Gluco-Hypo Kit (or similar) is available in an … (this text has been trimmed due to space limits). | PA High | 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… (this text has been trimmed due to space limits). | (i) Other assessment tools including cultural assessments and interRAI assessments were not consistently completed to identify key risk areas and to inform the care plan in all files reviewed. (ii) Care plans were not always developed and/or insufficient to specifically guide care for; a) falls management; b) Three of three residents with pressure injuries did not have documentation completed as required; c) behaviour management; d) mobility/transfer assistance and e) oral health. (iii) Allied … (this text has been trimmed due to space limits). | (i) Ensure risk assessment tools are used to inform care planning and when changes occur. (ii)-(iii) Ensure there is an up-to-date care plan in place that provides sufficient strategies to guide staff in caring for the resident. | PA High | 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… (this text has been trimmed due to space limits). | i) Where monitoring of care delivery is required, the requirements were not documented in the care plans: a) fluid monitoring for one PG resident with recurrent UTI; b) pressure relief and repositioning for one PG resident; c) bowel monitoring for one rest home resident; d). food chart for unplanned weight loss for one hospital level resident; e) toileting chart for one resident in the PG unit with recurrent falls. (ii). There was no evidence that behaviour monitoring charts were being regularl… (this text has been trimmed due to space limits). | (i) Ensure monitoring requirements as part of service delivery are documented in a care plan. (ii) Ensure behaviour charts are reviewed and de-escalation strategies and triggers are documented in the care plan. (iii) Ensure where acute changes in health status are identified that; a) that interventions are documented in a STCP or the LTCP updated; and b) when health issues become ongoing, that interventions are incorporated in the LTCP. | PA Moderate | 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. | The 2023 training programme was introduced to staff and is technically in place; however, there has been limited staff participation in certain subjects. Example (but not limited to): only four attended infection control and Falls management, and two attended abuse & neglect. | Ensure staff not attending mandatory training sessions are followed. | PA Low | In Progress | |
| Service providers ensure competent health care and support workers manage medication including: receiving, storage, administration, monitoring, safe disposal, or returning to pharmacy. | There are 20 staff who are listed as medicine-competent and nine of them did not have current medication competencies. One staff member who works in the psychogeriatric unit and rostered to administer medications has not had an updated medication competency since 2022. | Ensure that staff who administer medication maintain current medicine competency. | PA High | 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 … (this text has been trimmed due to space limits). | (i) Care plans and risk assessments were not updated following health changes identified through the care plan evaluation in four files reviewed (one hospital, two dementia, one PG). (ii) There was lack of documented evidence that care evaluations identify progress towards meeting goals in the same four files reviewed. | (i) Ensure risk assessments and care plans are updated following changes in health status. (ii) Ensure evaluations when it occurs identify progress towards meeting the goals. | PA Moderate | In Progress | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | Eight staff files were reviewed (one clinical manager, one activities coordinator, one cook, and five caregivers). Among these, two staff members had been employed for less than a year and were not yet due for performance evaluations. Of the remaining six, only one had an up-to-date performance appraisal, while the performance appraisals in the other files were last conducted in 2021. | Ensure that annual staff appraisals are completed. | PA Low | In Progress | |
| My complaint shall be addressed and resolved in accordance with the Code of Health and Disability Services Consumers’ Rights. | Complaints that exceeded the timelines of 10 and 20 days necessitate an update for the complainant. Two complaints, classified as clinical, extended over a period of three months without any recorded progress reporting and or updates provided to the complainant. The resolution of these clinical complaints falls under the management of governance. Advised that the complainants were contacted around the extended investigation time. However, this was not appropriately documented. | Ensure that complaints are documented as managed according to the Code and documentation reflects that the complainant is informed if complaint investigation exceeds 20 days. | 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
Before you begin
Before you download the audit reports, please read our guide to rest home certification and audits which gives an overview of the auditing process and explains what the audit reports mean.
What’s on this page?
Audit reports for this rest home’s latest audits can be downloaded below.
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.
Prior to 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) will appear on the rest home’s page. As the rest home completes the required actions, the status on the web site will update.
Audit reports
Audit date: 15 June 2022Audit type:Certification Audit
Audit date: 25 January 2021Audit type:Surveillance Audit
Audit date: 12 June 2019Audit type:Certification Audit
Audit date: 26 November 2018Audit type:Partial Provisional Audit
Audit date: 05 April 2018Audit type:Surveillance Audit