Alexander Lodge Rest Home

Profile & contact details

Premises details
Premises nameAlexander Lodge Rest Home
Address 5 Alexander Street Otahuhu Auckland 1062
Total beds23
Service typesPsychiatric, Rest home care
Certification/licence details
Certification/licence nameChetty's Investment Limited - Alexander Lodge Rest Home
Current auditorThe DAA Group Limited
End date of current certificate/licence24 April 2027
Certification period36 months
Provider details
Provider nameChetty's Investment Limited
Street address 6 Windy Ridge Road Glenfield Auckland 0629
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: 25 January 2024

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care.1. Updated copies of policies to meet Ngā Paerewa standards have been developed, but not released for staff to use as yet. 2. Document control processes are not robust. There are multiple out-of-date forms in use in some resident and staff records, in signs/information displayed in the facility, and there are multiple copies of different versions of some policies and procedures available for staff. 3. Internal audits undertaken in 2023 were completed utilising out-of-date audit templates. … (this text has been trimmed due to space limits).1. Provide to staff updated copies of policies and procedures that include all requirements to meet Ngā Paerewa standards. Update staff on key changes. 2. Review and implement robust document control process for clinical and staff related forms, policies, procedures and internal audits. 3. Ensure internal audits are undertaken using current template forms that align with the policies and procedures in use. PA LowIn Progress
Service providers shall provide educational resources that are available in te reo Māori and are accessible and understandable for Māori accessing services.Infection prevention and control educational resources are not available in te reo Māori. Ensure infection prevention and control educational resources are available in te reo Māori. PA LowIn Progress
Service providers shall develop and implement policies and procedures in accordance with good employment practice and meet the requirements of legislation.Police vetting has not occurred for any of the staff employed since the last audit. Undertake police vetting of new staff and retain records. PA LowIn Progress
The governance body shall identify the IP and AMS programmes as integral to service providers’ strategic plans (or equivalent) to improve quality and ensure the safety of people receiving services and health care and support workers.An antimicrobial stewardship programme is developed and documented to guide staff but is yet to be implemented. Ensure the antimicrobial stewardship programme is implemented. PA LowIn Progress
The following aspects of the system shall be performed and communicated to people by registered health professionals operating within their role and scope of practice: prescribing, dispensing, reconciliation, and review.Three-monthly medication reviews for all residents are not consistently being undertaken and the commencement dates are recently not being recorded on the medication prescribing section of the medication records reviewed. Ensure the three-monthly medication reviews for each individual resident are being undertaken by a medical officer and that the commencement dates are recorded on the prescribed medication records. PA ModerateIn 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 staff education/training programme does not include all components required to meet the ARRC contract and Ngā Paerewa standards Review and provide education to staff to meet all requirements of the ARRC contract and to meet Ngā Paerewa requirements, including equity, Te Tiriti o Waitangi, antimicrobial stewardship, abuse and neglect and restraint elimination. PA LowIn 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).Three-monthly medical reviews undertaken by a medical officer are not consistently occurring. To ensure all residents have a current medical review undertaken by a contracted medical officer or nurse practitioner to meet the Te Whatu Ora Te Toka Tumai Auckland contract obligations. PA ModerateIn Progress
Service providers shall establish environments that encourage collecting and sharing of high-quality Māori health information.The CM is yet to determine how the collection and sharing of high-quality Māori health information is to occur. Implement a process to facilitate the collection and sharing of high-quality Māori health information. PA LowIn 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.

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