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 - Armourdene Rest Home
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence23 May 2020
Certification period24 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: 18 June 2019

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
A process to measure achievement against the quality and risk management plan is implemented.The administration manager completes the non-clinical audits as scheduled, completes a summary of audits, addresses any corrective actions and reports outcomes at the monthly staff meeting. Clinical audits have not been completed for 2017 as per the schedule including admissions, care plans, continence, medication infection control and safe manual handling. Ensure all clinical audits are completed by the RN as scheduled in the internal audit calendar. PA LowReporting Complete15/04/2019
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.1) There was no documented evidence of RN follow-up for three of six incidents (two unwitnessed falls and one medication error). 2) Head injury observations for three unwitnessed falls with suspected head injury had not been completed as per protocol. 1) Ensure there is a clinical assessment and follow-up completed for all incidents. 2) Ensure head injury observations are completed. PA ModerateReporting Complete15/04/2019
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) There was no documented evidence on delivery of medications reconciled against the medication chart. (ii) Four of twelve medication charts had signing gaps around administration of inhalers and medications when on leave and signing sheets did not correspond with the medication charts. (iii) Restricted medication weekly checks had not been completed for the month of January 2018 and part of December 2017. (iv) The GP had not reviewed four of twelve medication charts at least three mo… (this text has been trimmed due to space limits).(i) Ensure evidence of medicine reconciliation is documented. (ii) Ensure medications are signed when administered or ‘the reason not given’ is recorded. (iii) Ensure weekly checks of restricted medications are completed weekly. (iv) Ensure GPs review the medication charts at least three monthly. PA ModerateReporting Complete15/04/2019
All buildings, plant, and equipment comply with legislation.The paint is worn on kitchen cupboard surfaces leaving them porous. The flooring surfaces are worn and cracked in areas. The kitchen requires repairs to ensure infection control standards are being met. Ensure all kitchen surfaces are sealed to meet infection control standards. PA LowReporting Complete15/04/2019
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.The following shortfalls were identified in the files reviewed: (i) There were no monthly weight and observation records in four files reviewed. (ii) There was no behaviour monitoring chart in place for one resident with challenging behaviours as reported in progress notes. (iii) The frequency of dressing changes and evaluations for two of two wounds had not been consistently documented. (i) Ensure weight and observations are taken and recorded monthly. (ii) Ensure behaviour monitoring is implemented for residents with behaviours. (iii) Ensure wound documentation evidences evaluation and frequency of reviews. PA ModerateReporting Complete15/04/2019
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.Two of five long-term care plans and one short-stay care plan did not include the required support and interventions to meet the resident goals for: (i) Management of anxiety/restlessness and shortness of breath. (ii) There was no challenging behaviour management plan in place including triggers and interventions. (iii) There were no documented early warnings signs/symptoms of declining mental health for one short-term care resident under CTO. Ensure that care plans document required supports and interventions to reflect the residents’ current needs. PA LowReporting Complete15/04/2019
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.1) The interRAI assessments had not been completed within 21 days for two long-term residents. InterRAI assessments had not been utilised six monthly for two long-term residents. 2) Four of five long-term resident care plans had not been completed within 21 days and not evaluated six monthly. Ensure that interRAI assessments and care plans are completed within contracted timeframes. PA LowReporting Complete15/04/2019
All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.(i) Not all of the dry goods that had been decanted into sealed containers had an expiry date recorded on the container. (ii) Cleaning schedules for the kitchen are not documented as being maintained. (i) Ensure that all dry goods decanted from manufacturers packing have an expiry date recorded on them. (ii) Ensure the kitchen cleaning schedule is documented as completed. PA LowReporting Complete15/04/2019
The facilitation of safe self-administration of medicines by consumers where appropriate.On the day of audit, there was one resident who was self-administering. The assessment completed by the RN did not evidence GP input as per policy. The monitoring of self-administration of the residents’ inhalers and creams was not recorded. Ensure there is documented evidence of GP input into the assessment of self-medicating residents and there is documented evidence of monitoring as per policy. PA LowReporting Complete15/04/2019
Service providers responsible for medicine management are competent to perform the function for each stage they manage.One long-serving RN did not have an annual medication competency completed. Two newly appointed RNs did not have medication competency completed. One RN who was orientating on the day of audit was administering medications. Ensure RNs complete annual medication competencies. PA ModerateReporting Complete15/04/2019
Consumers have a right to full and frank information and open disclosure from service providers.Eleven of twelve incident forms and progress note entries did not evidence family had been notified of the incident Ensure families are advised of adverse events or if not, then the reason for not notifying them is documented PA LowIn Progress
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Education on the following topic has not been provided at least biannually: cultural safety, falls minimisation, abuse and neglect and pressure injury prevention and management. Infection control education for staff has not been provided at least annually. Ensure all required education is provided for staff. PA LowReporting Complete18/09/2019
Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome.Progress towards achievement of resident’s care plan goals was not documented in the files of four long-term residents reviewed. Ensure care plan evaluations include progress towards the resident’s goals. PA LowReporting Complete18/09/2019
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.(i) The assessment of three wounds was not fully documented. (ii) The frequency of dressing changes and evaluations for two of two wounds had not been consistently documented. (iii) There was no behaviour monitoring chart in place for one resident with challenging behaviours as reported in progress notes. (i) to (ii) Ensure wound documentation evidences assessment evaluation and frequency of reviews. (iii) Ensure behaviour monitoring is implemented for residents with behaviours. PA ModerateReporting Complete18/09/2019
All buildings, plant, and equipment comply with legislation.The flooring surfaces in the kitchen are worn and cracked in areas. The kitchen requires repairs to ensure infection control standards are being met. Ensure kitchen flooring is replaced as planned to meet infection control standards. PA LowReporting Complete18/09/2019
A process to measure achievement against the quality and risk management plan is implemented.Internal audits have not been completed for 2018 and 2019 as per the schedule including (but not limited to) admissions, privacy, foundation of care employment and orientation, family care, continence, infection control, safe manual handling and care and hygiene. Ensure all clinical audits are completed as scheduled in the internal audit calendar. PA ModerateReporting Complete18/09/2019
All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.Not all of the dry goods that had been decanted into sealed containers had an expiry date recorded on the container. Ensure that all dry goods decanted from manufacturers packing have an expiry date recorded on them. PA LowReporting Complete18/09/2019
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) The interRAI assessments had not been completed within 21 days for two long-term residents. (ii) InterRAI assessments had not been utilised six monthly for two long-term residents. (iii) Two long-term resident care plans had not been completed within 21 days. (iv) The long-term care plan had not been evaluated six monthly for two residents. (v) The respite resident did not have a current initial assessment or care plan. (i)-(v) Ensure that initial assessments, interRAI assessments and care plans are completed within contracted timeframes. PA ModerateReporting Complete18/09/2019
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.(i) There was no documented evidence of RN follow-up for five of twelve incidents (two unwitnessed falls, two behaviours and one other). (ii) Head injury observations for two unwitnessed falls with suspected head injury had not been completed as per protocol. (iii) Eleven of twelve incidents did not evidence consideration of opportunities to minimise future events. (i) Ensure there is a clinical assessment and follow-up completed for all incidents. (ii) Ensure head injury observations are completed. (iii) Ensure opportunities to identify, minimise or manage the risk are considered and documented. PA ModerateReporting Complete18/09/2019
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.Four of four long-term care plans and one respite care plan did not include the required support and interventions: Examples include; (i) Management of falls preventions and mobility requirements for one long-term resident. (ii) Management of incontinence for two long-term residents. (iii) Management of diabetes for one long-term and one respite resident. (iv) There were insufficient details for managing challenging behaviours for two long-term residents including triggers and intervent… (this text has been trimmed due to space limits).(i)- (iv) Ensure that care plans document required supports and interventions to reflect the residents’ current needs. PA ModerateReporting Complete18/09/2019
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) The respite resident did not have a signed medication chart. (ii) The GP had not reviewed two of ten medication charts at least three monthly. (i) Ensure all residents have a signed medication chart. (ii) Ensure GPs review the medication charts at least three monthly. PA ModerateReporting Complete18/09/2019
The service is able to demonstrate that written consent is obtained where required.Two of five files reviewed (including the respite resident) did not have a signed admission agreement on file. Ensure all residents have a signed admission agreement on file. PA LowReporting Complete18/09/2019

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.

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