Armourdene Rest Home

Profile & contact details

Premises details
Premises nameArmourdene Rest Home
Address 10 Von Tempsky Street Hamilton East Hamilton 3216
Total beds28
Service typesRest home care
Certification/licence details
Certification/licence nameWilding International Limited
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence23 May 2018
Certification period36 months
Provider details
Provider nameWilding International Limited
Street address 10 Von Tempsky Street Hamilton East Hamilton 3216
Post addressPO Box 855 Waikato Mail Centre Hamilton 3240

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: 01 December 2016

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Information is entered into the consumer information management system in an accurate and timely manner, appropriate to the service type and setting.Time of entry is not being documented in the resident’s progress notes. Ensure progress notes include the time of entry. PA LowReporting Complete06/01/2016
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.(i) There were no documented early warning signs and symptoms for a decline in mental health status for one resident as per psychologist correspondence. (ii) Epileptic seizures have not been recorded on the seizure chart as per care plan instructions. (i) Ensure interventions for changes in health status are documented. (ii) Ensure charts are completed as instructed PA LowReporting Complete05/02/2016
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.The audit schedule that is documented for the service has not been implemented. There is a lack of evidence to reflect quality and risk management results being regularly communicated to staff. Ensure the internal audit programme is up-to-date and is being implemented by the service with results communicated to staff. PA LowReporting Complete05/02/2016
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.There is a lack of evidence to reflect that performance appraisals for staff are conducted annually. Ensure staff performance appraisals are conducted annually, in accordance to policy. PA LowReporting Complete05/02/2016
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.Internal audits were implemented from January to March 2016, however identified issues and deficiencies were not followed up, and required action plans were not signed off as completed. Several issues were also identified in the staff meetings but follow up on these issues was not documented. Ensure that corrective actions are implemented and signed off as completed. PA LowIn Progress
Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include: (a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk; (b) A process that addresses/treats the risks associated with service provision is developed and im… (this text has been trimmed due to space limits).(i)The health and safety policies have not been updated yet to align with new Health and Safety at Work Act 2015; (ii) The hazard register has not been reviewed in the last 12 months and does not include current reported hazards. Ensure that health and safety policies are reviewed and align with the updated Health and Safety at Work Act 2015; (ii) Ensure the hazard register is reviewed and up to date. PA LowIn Progress
The facilitation of safe self-administration of medicines by consumers where appropriate.On the day of audit, there was one resident who self-administers medicine who had an up-to-date competency assessment. Self-administration competency was regularly reviewed by the RNs and the GP but self-administration of medicines on a daily basis was not recorded. Ensure that self-medication is monitored and recorded in the resident’s medication file. PA LowIn Progress
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.Six resident files reviewed showed that two out of six interRAI assessments were not completed within six months and care plan evaluations were overdue for these residents. Further samples of three files evidenced that two of them were not reviewed within six months. On interview with both RNs confirmed that due to unavailability of the third RN who was on maternity leave, they were unable to keep up with their work load. Ensure that interRAI assessments and care plan evaluations are completed at least six monthly. PA LowIn Progress
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.One out of six files reviewed showed that administration of prn medication and pain management were lacking RN input. For example: (i)- An elixir form of a controlled drug was stopped and a tablet form was re-started, however staff continued to use the liquid form because new tablets were not received from the pharmacy. (ii) Resident progress notes and pain assessments showed that the resident was complaining about pain, however an ‘as required’ controlled drug was prescribed 4-6 hourly was only… (this text has been trimmed due to space limits).Ensure that there is registered nurse involvement in pain management and appropriate use of prn medication. PA LowIn Progress
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.(i)The internal audit schedule has not been fully implemented. Therefore, there is a lack of documented evidence to reflect internal audit results being fully communicated to staff. (ii) Fridge temperatures monitoring did not occur since September 2016. (iii) There have been no consumer satisfaction surveys since 2013. (vi) The internal audit schedule includes the quality review of the programme which was scheduled in April 2016; however, this review has not been completed. Ensure that the quality programme is fully implemented. PA ModerateIn Progress
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.(i)In one occasion, a controlled drug not administered was returned to the safe, but it was only signed by one staff member. The medication chart was signed to acknowledge that this controlled drug was administered. Progress notes identified that the resident was unconscious and transferred to the public hospital. Therefore, the controlled drug was not administered. (ii) Two out of ten medication charts had signing gaps. (iii) One insomnia medication was charted once a day but in one occasion… (this text has been trimmed due to space limits).(i)Ensure that two staff sign for controlled drugs. (ii) Ensure that medications are signed when administered or ‘the reason not given’ is recorded. (iii) Ensure that medication is administered as prescribed. PA ModerateIn 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. 

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 reports

Audit date: 01 December 2016

Audit type:Surveillance Audit

Audit date: 03 March 2015

Audit type:Certification Audit

Audit date: 20 January 2014

Audit type:Surveillance Audit

Audit date: 15 March 2012

Audit type:Certification Audit

Audit date: 26 April 2011

Audit type:Surveillance Audit

Audit date: 18 March 2010

Audit type:Certification Audit

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