Annaliese Haven Rest Home

Profile & contact details

Premises details
Premises nameAnnaliese Haven Rest Home
Address 25 Adderley Terrace Kaiapoi 7630
Total beds61
Service typesDementia care, Rest home care, Geriatric
Certification/licence details
Certification/licence nameElsdon Enterprises Limited - Annaliese Haven Rest Home
Current auditorThe DAA Group Limited
End date of current certificate/licence01 July 2025
Certification period36 months
Provider details
Provider nameElsdon Enterprises Limited
Street address 1 Taaffes Glen Road Rangiora 7472
Post address1 Taafes Glen Road RD 2 Rangiora 7472

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: 03 October 2023

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.The service has a quality framework which includes clinical incident reporting, such as falls, skin tears, pressure injuries, resident and whanau satisfaction surveys and infection prevention data. The data is reviewed month on month, however there is no analysis being carried out on the data. Quality data collected is analysed to ensure the steps being taken are making a difference to patient outcomes. This includes trends for individuals where applicable, and with types of incidents over time. PA ModerateReporting Complete29/09/2022
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.Not all residents have the required assessments and long-term care planning completed within the contractually required timeframes. Not all short term care plans reflected residents changing needs. A short term care plan for a resident recently discharged from hospital did not include the requirement for thickened fluids and a puree diet For residents admitted in 2022: Six residents have not had an interRAI assessment completed since admission and one resident had an interRAI assessment complete… (this text has been trimmed due to space limits).Take actions to ensure all residents have an interRAI assessment and long-term care planning completed within the contractually required timeframe. PA ModerateReporting Complete20/12/2022
A medication management system shall be implemented appropriate to the scope of the service.Not all elements of the medication management system as implemented meet the expected standard to enable safe administration of medications: The service will ensure: All medications contain a legible label including the resident’s name and required prescription details. The date of opening of eye drops and ointments is recorded. Medication is stored safely with a cap or nozzle replaced on ointments once opened. All individual resident equipment used to administer medication, such as a spacer used for inhaled medication, is labelled to identify the resident. PA ModerateReporting Complete20/12/2022
The nutritional value of menus shall be reviewed by appropriately qualified personnel such as dietitians.The service has modified the menu approved by the dietitian and is unable to confirm the menu meets the nutritional guidelines for older people. The service ensures the menu followed is approved by a qualified dietitian PA LowReporting Complete20/12/2022
The physical environment, internal and external, shall be safe and accessible, minimise risk of harm, and promote safe mobility and independence.There are areas where maintenance is required around the facility, such as chipped walls, showers where the wall covering is coming away, delamination of furnishings, and other areas requiring attention identified during a recent internal audit. Another area requiring attention is the laundry, where the vinyl flooring is broken at the coving beside the washing machine. The room behind the drier is used for hanging residents’ clothes and staff are in and out of the area, the floor is badly brok… (this text has been trimmed due to space limits).Maintenance areas identified by the internal audit and during this audit are attended to to ensure the safety of staff and residents. PA LowReporting Complete20/12/2022
Service providers shall develop written IP policies with input from suitably qualified personnel, which comply with relevant legislation and accepted best practice. The suite of policies shall include: (a) Hand hygiene and standard precautions; (b) Aseptic technique; (c) Transmission-based precautions; (d) Prevention of sharps injuries; (e) Prevention and management of communicable infectious diseases in service providers and users; (f) Management of current and emerging multi-drug-resistant org… (this text has been trimmed due to space limits).Single use items are not discarded after use as required by the organisation’s policy and there is no clear process for the disinfection of reusable wound care instruments. No auditing of decontamination and disinfection of any medical instruments was occurring. The service ensures staff are aware of the policy related to single use items and that there is a clear procedure for staff to follow when disinfecting reusable wound care instruments. Conduct audit of the decontamination and disinfection of any medical instruments that are used and reused for wound care. PA ModerateReporting Complete20/12/2022
Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services.Staff reported feeling under pressure with the increase in the numbers of hospital level care residents. It was noted that the ‘floating’ person in the dementia wing has not been replaced on several occasions on the roster. The activities programme has reduced with caregivers not being available to provide activities. This is particularly evident in evening and weekends in the dementia unit and for hospital level care residents who do not attend group activities. The laundry hours have been re… (this text has been trimmed due to space limits).The organisation reviews the number of staffing hours related to their increasing hospital population to ensure staff can give the care they require. The activities programme be reviewed to ensure it is meeting the needs of the residents and in particular in the dementia wing. Review of the tasks undertaken by the laundry staff in the hours they now have. PA LowReporting Complete01/05/2023
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.Individual care or support plans have not been completed within the required contractual timeframe All resident’s interRAI assessments and all long-term care plans to be completed within the facility's required contractual timeframe. PA ModerateIn 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.The review of staffing levels show that sufficient healthcare and support workers are on duty to provide safe services. The activity staff are employed to provide activities on weekdays, with no structured activity programme available on the weekends, or after hours in the dementia unit. Implement an activity program that includes activities for residents during the weekend days and includes activities that are available for residents in the dementia unit 24/7. PA ModerateIn Progress
Service providers shall evaluate progress against quality outcomes.The quality framework does not include defined quality outcomes that are being worked towards and therefore quality outcomes are not being evaluated as required by the standard. As part of the facility’s quality framework, identify and set quality outcomes for the facility to work towards, and evaluate progress against these outcomes on a regular basis. PA ModerateIn Progress
The Code of Health and Disability Services Consumers’ Rights and the complaints process shall work equitably for Māori.There is a complaint process in place, but it does not include a system to ensure the complaints process works equitably for Māori. Implement processes to monitor and evidence that the organisation’s complaints process works equitably for Māori. PA LowIn Progress
Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care.There is reporting of clinical data, with limited analysis occurring, however no critical thinking or benchmarking is being completed to help inform clinical practice. Collect clinical data, inclusive of ethnicity data, and complete analysis of this information involving critical thinking and benchmarking to inform clinical practice. PA ModerateReporting Complete21/02/2024
Service providers shall implement systems to determine and develop the competencies of health care and support workers to meet the needs of people equitably.Not all staff had completed the required competencies as outlined and defined in the organisation’s training policy. Ensure all staff have completed the required competencies specific to their role, and within the specified timeframes, as outlined in the organisation’s training policy. PA LowReporting Complete21/02/2024
Surveillance methods, tools, documentation, analysis, and assignment of responsibilities shall be described and documented using standardised surveillance definitions. Surveillance includes ethnicity data.Surveillance records are incomplete as there is no evidence of either trend analysis or of ethnicity data. Provide monthly trend analysis of infection rates that includes ethnicity data. PA LowReporting Complete21/02/2024

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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