Albany Home and Hospital

Profile & contact details

Premises details
Premises name	Albany Home and Hospital
Address	28 Albany Street Gore 9710
Total beds	25
Service types	Rest home care, Geriatric

Certification/licence details
Certification/licence name	Experion Care NZ Limited - Albany Home and Hospital
Current auditor	Health and Disability Auditing New Zealand Limited
End date of current certificate/licence	08 September 2024
Certification period	36 months

Provider details
Provider name	Experion Care NZ Limited
Street address	283 Kennedy Road Onekawa Napier 4112
Post address	283 Kennedy Road Pirimai Napier 4112

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: 12 December 2022

Outcome required	Found at audit	Action required	Risk rating	Action status	Date action reported complete
Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.	i) There is no fire evacuation scheme that meets current legislation ii)There was no documented evidence of formal fire evacuation training had occurred since July 2019 as per legislation.	Ensure the fire evacuation scheme and six-monthly fire evacuations are completed as per legislation.	PA Moderate	Reporting Complete	18/08/2022
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.	There have been no official meetings held at the facility since the change of ownership. This includes, resident, staff, health and safety, infection prevention and control, restraint and quality improvement.	Provide evidence formal meetings are held regularly and document evidence that information has been provided to key stakeholders.	PA Moderate	Reporting Complete	18/08/2022
There is a document control system to manage the policies and procedures. This system shall ensure documents are approved, up to date, available to service providers and managed to preclude the use of obsolete documents.	(i)there is no documented evidence the policies and procedures have been reviewed or updated since the change of ownership. (ii)Policies were noted not to have a date to reference as to date of review or authorisation (ii)Polices referred to an email address which is the previous owners contact details (iv)There were a number of versions of the same policy with no indication which was the current policy (v)The restraint polices were dated last reviewed 2017.	Ensure all policies and procedures are managed to ensure all documents are approved, up to date and a system is introduced to manage the use of obsolete documents.	PA Low	Reporting Complete	18/08/2022
The appointment of appropriate service providers to safely meet the needs of consumers.	(i)there was no evidence of police checking for any new employee (ii)Registered nurses have been allocated the positions of infection prevention and control and restraint coordinators: however, positions descriptions were not evident in the staff members files.	Ensure human resource management processes meet current good employment practice.	PA Moderate	Reporting Complete	18/08/2022
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.	(i)Not all staff have completed the required orientation programme. (ii)not all staff have competed the mandatory annual training and education	Provide evidence all staff have completed the required orientation programme and mandatory training requirements.	PA Moderate	Reporting Complete	18/08/2022
Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.	The menu has not been reviewed by the registered dietitian since 2018	Ensure menu is reviewed every two years by a registered dietitian, to comply with recognised nutritional guidelines	PA Low	Reporting Complete	18/08/2022
A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines.	(i)Registered Nurses currently transcribe medications. (ii) outcome of PRN medications not documented for effectiveness. (iii)six monthly stocktaking of controlled drugs has not been completed. (IV) Un known Allergies, No known Drug Allergies (NKDA) not documented for residents with no allergies (V) Medication was stored in the food fridge. (VI) Controlled drug was stored in locked cupboard in the residents dining room, not in a compartment that was constructed of metal or concrete. … (this text has been trimmed due to space limits).	Ensure all medication management process meets legislative and best practice requirements:	PA Moderate	Reporting Complete	18/08/2022
All buildings, plant, and equipment comply with legislation.	The testing and tagging of equipment and calibration of biomedical equipment was not current.	Ensure the testing and tagging of equipment and calibration of biomedical equipment is current.	PA Moderate	Reporting Complete	18/08/2022
Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services.	The service cannot provide RN cover 24 hours a day, across seven days, to meet the requirement of the ARRC contract with Te Whatu Ora Southern.	Ensure a registered nurse is engaged to meet the requirements of the ARRC contract clause D17.3 e i-viii.	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 was no evidence of an annual review of the infection control programme for 2021.	Ensure the infection control programme is reviewed at least annually.	PA Low	Reporting Complete	05/04/2023
Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care.	Satisfaction surveys could not be located for 2020, 2021, or 2022 (year to date).	Ensure residents and relatives have the opportunity to provide feedback around all aspects of the service.	PA Low	Reporting Complete	22/06/2023

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: 12 December 2022

Audit type:Surveillance Audit

Audit date: 13 July 2021

Audit type:Certification Audit

Audit date: 02 July 2020

Audit type:Provisional Audit

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