Amberlea Hospital and Rest Home
Profile & contact details
|Premises name||Amberlea Hospital and Rest Home|
|Address||665 Mahurangi East Road Algies Bay Warkworth 0920|
|Service types||Rest home care, Geriatric, Medical|
|Certification/licence name||CHT Healthcare Trust - Amberlea Hospital and Rest Home|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||29 June 2019|
|Certification period||36 months|
|Provider name||CHT Healthcare Trust|
|Street address||97 Great South Rd Market Road Auckland 1543|
|Post address||PO Box 74341 Market Road Auckland 1543|
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: 05 October 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk.||Six current pressure injuries and two healed pressure injuries identified had not been included in the incident reporting system or incident data.||Ensure all pressure injuries are captured as incidents and included in incident data analysis||PA Low||Reporting Complete||15/08/2016|
|The appointment of appropriate service providers to safely meet the needs of consumers.||Two of seven staff files sampled did not contain a documented reference check.||Ensure that a reference check is completed and documented for all new staff employed.||PA Low||Reporting Complete||15/08/2016|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Three of seven staff files sampled did not have a documented orientation and a further two files did not have the orientation documentation fully completed.||Ensure that all new staff completes an orientation programme.||PA Low||Reporting Complete||15/08/2016|
|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.||Three medications for three residents had not been administered as prescribed by the GP.||Ensure all medications are administered as prescribed.||PA Moderate||Reporting Complete||15/08/2016|
|Service providers responsible for medicine management are competent to perform the function for each stage they manage.||Seven RNs have not completed annual competencies.||Ensure all RNs complete medication competencies annually.||PA Moderate||Reporting Complete||15/08/2016|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||The three kitchenette fridges contain resident food items, perishable goods and protein drinks. There was no evidence of temperature monitoring for these fridges.||Ensure all fridges containing resident foods and perishable goods have temperatures monitored and recorded.||PA Low||Reporting Complete||15/08/2016|
|Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer.||Two resident files (one hospital and one rest home) did not evidence GP admission visits within two working days.||Ensure GP admission visits occur within two working days.||PA Low||Reporting Complete||15/08/2016|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||1) Weights had not been completed at the required frequency documented in care plans for three residents (two rest home and one hospital resident). There was no weight loss report for one rest home resident commenced on REAP. 2) The weight loss report has not been updated for one hospital resident to reflect recent weight loss. 3) There are no documented interventions for the management of hypoglycaemia and hyperglycaemia for one rest home resident on insulin. 4) One hospital resident with t… (this text has been trimmed due to space limits).||1) Ensure weight monitoring is completed as documented in the care plans. 2) Ensure weight loss reports are implemented/reviewed to reflect the resident’s nutritional status. 3) Document interventions for the management of hypoglycaemia and hyperglycaemia, for insulin dependent residents. 4) Ensure each pressure injury has individual wound assessments and wound evaluations.||PA Moderate||Reporting Complete||15/08/2016|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Quality/health and safety meeting minutes document numbers of incidents by type for the period but no discussion around the trends or data analysis. Health care assistants confirmed this finding.||Ensure that all service providers are informed of the results of accident/incident data analysis and evaluations.||PA Low||Reporting Complete||16/08/2016|
|The appointment of appropriate service providers to safely meet the needs of consumers.||Three of five staff files reviewed of staff hired in 2017 were missing evidence of reference checking.||Ensure reference checking is completed prior to employing new staff.||PA Low||Reporting Complete||14/03/2018|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Two of five staff files reviewed were missing evidence that they had completed their orientation programme.||Ensure staff files contain evidence of staff completing their orientation programme.||PA Moderate||Reporting Complete||14/03/2018|
The outcome required by the Health and Disability Services Standards.
Found at audit
The issue that was found when the rest home was audited.
The action necessary to fix the issue, as decided by the auditor.
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.
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.
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.
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 Health and Disability Services Standards.
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 reportsAudit date: 05 October 2017
Audit type:Surveillance Audit
- Amberlea Hospital and Rest Home - Oct 2017 (docx, 33.2 KB)
- Amberlea Hospital and Rest Home - Oct 2017 (pdf, 131.19 KB)
Audit type:Certification Audit
- Amberlea Hospital and Rest Home - Apr 2016 (docx, 44.2 KB)
- Amberlea Hospital and Rest Home - Apr 2016 (pdf, 170.26 KB)
Audit type:Surveillance Audit
- Amberlea Hospital and Rest Home - Feb 2015 (docx, 44.61 KB)
- Amberlea Hospital and Rest Home - Feb 2015 (pdf, 129.85 KB)
Audit type:Certification Audit; Verification Audit
Audit type:Surveillance Audit