Anne Maree Gardens
Profile & contact details
|Premises name||Anne Maree Gardens|
|Address||24 Coronet Place Avondale Auckland 1026|
|Service types||Rest home care, Psychogeriatric, Geriatric, Medical, Physical|
|Certification/licence name||Logan Samuel Limited - Anne Maree Gardens|
|Current auditor||The DAA Group Limited|
|End date of current certificate/licence||17 June 2024|
|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: 27 January 2022
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||The manager is aware that the new wing will have to be adequately covered by registered nurses 24 hours a day seven days a week. One registered nurse and additional allied health staff will be required to cover this new area of service provision and increase in capacity to meet the needs of the residents.||To ensure the facility is adequately staffed to meet the increased numbers of residents who are assessed as requiring hospital level and rest home level care.||PA Low||Reporting Complete||04/05/2022|
|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.||Outcomes of PRN medicines administered were not being consistently documented in all medication charts sampled.||Ensure administered PRN medicine outcomes are documented for effectiveness.||PA Moderate||Reporting Complete||20/07/2021|
|Service providers responsible for medicine management are competent to perform the function for each stage they manage.||There was no evidence of current medication competency for the clinical leader, this was last completed in 2017.||Provide evidence of current medication competency for the clinical leader.||PA Moderate||Reporting Complete||20/07/2021|
|The organisation has a clearly defined and documented infection control programme that is reviewed at least annually.||The infection control programme was not reviewed annually.||Provide evidence of an annually reviewed infection control programme.||PA Low||Reporting Complete||20/07/2021|
|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.||(i)There were 12 overdue interRAI assessments. (ii)Post fall assessments are not being completed when a resident has a fall. (iii) Neurological observations are not always being completed on residents who have had a fall and sustained a head injury or those who have had an unwitnessed fall. The observations are not always taken over the timeframe required as per the adverse event policy and procedure.||(i)Ensure all interRAI assessments are completed within timeframes that safely meet the needs of the residents and ARCC contract requirements. (ii)Ensure a falls assessment is completed after a resident has a fall. (iii) Ensure neurological observations are completed on all residents who sustain a head injury and/or those residents who have had an unwitnessed fall. The observations are to be completed for the required timeframe as per the policy in place.||PA Moderate||Reporting Complete||06/09/2021|
|All buildings, plant, and equipment comply with legislation.||Not all essential equipment and resources are available on site (although ordered) such as beds, bedroom furniture, lounge/dining furniture, consumables. The external deck is to be completed as per the building plan sighted. Safety rails in the bathrooms/toilets and hallway handrails are yet to be installed. A certificate for public use will need to be obtained prior to occupancy.||Ensure the external deck is completed and all essential equipment and resources are readily available and installed prior to opening the facility In addition to this a Certificate of Public Use will be required and displayed prior to occupancy.||PA Low||In Progress|
|The appointment of appropriate service providers to safely meet the needs of consumers.||Positions for an additional registered nurse, a kitchenhand, two cleaners and one laundry staff member have been advertised. The appointment of appropriate service providers remains in progress and therefore could not be verified.||Appropriate service providers are appointed to safely meet the needs of residents prior to commencement of the service.||PA Low||Reporting Complete||20/04/2022|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||An orientation pack, handbook and orientation checklists have been developed in readiness for the appointment of new staff.||The orientation programme that covers the essential components of the facility and services provided is completed by all new staff employed prior to commencement of the service. Evidence of staff completing the relevant orientation will be required.||PA Low||Reporting Complete||20/04/2022|
|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.||The design and the plan for the medication room was sighted but was not completed on the day of the audit. Storage and contents could not be reviewed. The medication room will need to be a locked room, and this is yet to be installed.||Provide evidence of the completion of the medication room and that all requirements for security, storage of medicines and controlled drugs, equipment and resources are in place and readily available to staff.||PA Low||Reporting Complete||20/04/2022|
|There are adequate numbers of accessible toilets/showers/bathing facilities conveniently located and in close proximity to each service area to meet the needs of consumers. This excludes any toilets/showers/bathing facilities designated for service providers or visitor use.||Bathroom areas are easily identified but were not completed at the time of the audit.||Ensure all fixtures and fittings, vanities and toilets and shower units are installed prior to occupancy.||PA Low||Reporting Complete||20/04/2022|
|Adequate access is provided where appropriate to lounge, playroom, visitor, and dining facilities to meet the needs of consumers.||The manager provided documentation of the furniture/furnishings and flooring which has been ordered and delivery dates are arranged. Both the dining and lounge areas are of an adequate size to accommodate twenty residents comfortably but need to be completed prior to occupancy.||Ensure the communal areas for entertainment, recreation and dining are completed prior to occupancy.||PA Low||Reporting Complete||20/04/2022|
|Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.||A fire drill is required before the new configuration/area can be approved. The next facility six monthly fire drill is due February 2022, and the manager is planning to include the new area of service in this drill which will be required prior to gaining approval and prior to occupancy. In addition to this, the fire approval scheme will need to be reviewed and approved by the New Zealand Fire Service, as this was not verified on the day of the audit in relation to the new building.||Provide evidence that a fire drill has occurred with all staff involved for the new area of service, and that this occurs in a timely manner prior to occupancy. Ensure the fire evacuation scheme has been reviewed and approved by the New Zealand Fire Service.||PA Low||Reporting Complete||20/04/2022|
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.
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 reportsAudit date: 27 January 2022
Audit type:Partial Provisional Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Partial Provisional Audit
Audit type:Surveillance Audit; Partial Provisional Audit