Anne Maree Court
Profile & contact details
|Premises name||Anne Maree Court|
|Address||17 Fraser Avenue Northcote Auckland 0627|
|Service types||Rest home care, Geriatric|
|Certification/licence name||Logan Samuel Limited - Anne Maree Court|
|Current auditor||The DAA Group Limited|
|End date of current certificate/licence||12 June 2021|
|Certification period||36 months|
|Provider name||Logan Samuel Limited|
|Street address||24 Coronet Place Avondale Auckland 1026|
|Post address||PO Box 19095 Avondale Auckland 1746|
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: 19 April 2018
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||The care plan developed by an external nurse specialist to support the resident while rehabilitating after an injury before returning home has not been followed to ensure that the individual needs of the resident were being met and the requests/instructions of the allied supporting staff were followed. A distressed and escalating (with anger) resident was unattended to for a period of time on day two of the audit. The interventions in the care plan were not being carried out.||To provide evidence that all interventions and evaluations are carried out in practice.||PA Low||In Progress|
|The facilitation of safe self-administration of medicines by consumers where appropriate.||The safe facilitation of two residents’ who are self-administering medication was not evident.||To provide evidence that residents self-medicating comply with legislation and medication guidelines.||PA Moderate||Reporting Complete||07/08/2018|
|The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.||The provider has not meet the requirements regarding essential notifications under Section 31 of the Health and Disability Services (Safety) Act 2001 which requires all certified providers to notify the Director General of Health.||Ensure that events that require reporting under section 31 are notified.||PA Low||Reporting Complete||05/12/2018|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||The number of staff allocated does not appear to take into account: - the layout of the facility. This is a large square with no observation points in corridors (although CCTV has been recently installed). Care staff were seldom seen in these areas although a large number of rest home residents were either in their rooms or wandering the corridors. - the high dependency needs of the majority of residents and the changing and challenging behaviour of others. The system for back filling unexp… (this text has been trimmed due to space limits).||Review the number of care staff and RNs on each shift considering the acuity, high dependency needs and challenging behaviour of residents, and the layout of the facility. Strengthen the system for back filling staff absences.||PA Moderate||Reporting Complete||05/12/2018|
|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.||Medication administration processes were not undertaken in accordance with the organisational policy and good medication practice in relation to, the written acknowledgment of dates when medication (eye drops/ointments) are opened, documentation and follow-thru and/or outcomes of medication being either withheld or not administered by staff, and the administration of medication to individual residents.||Provide evidence that a safe medicines management system is implemented to comply with legislation and medication guidelines.||PA Moderate||Reporting Complete||04/02/2019|
|In assessing whether restraint will be used, appropriate factors are taken into consideration by a suitably skilled service provider. This shall include but is not limited to: (a) Any risks related to the use of restraint; (b) Any underlying causes for the relevant behaviour or condition if known; (c) Existing advance directives the consumer may have made; (d) Whether the consumer has been restrained in the past and, if so, an evaluation of these episodes; (e) Any history of trauma or abuse, whi… (this text has been trimmed due to space limits).||There is no documented evidence that a resident with bedrails in use, had been assessed prior to initiating the restraint.||Ensure that all procedures related to the restraint process are adhered to.||PA Low||Reporting Complete||01/07/2019|
|Where an episode of restraint is ongoing the time intervals between evaluation processes should be determined by the nature and risk of the restraint being used and the needs of the consumers and/or family/whānau.||There has not been a review of the restraint intervention since it was initiated in September 2017.||Ensure all restraint interventions are reviewed and evaluated at times intervals relevant to the degree of risk and type of restraint in place.||PA Low||Reporting Complete||01/07/2019|
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: 19 April 2018
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit