Ascot Care Home
Profile & contact details
|Premises name||Ascot Care Home|
|Address||149 Racecourse Road Glengarry Invercargill 9810|
|Service types||Physical, Dementia care, Rest home care, Geriatric, Medical|
|Certification/licence name||Bupa Care Services NZ Limited - Ascot Care House|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||04 December 2021|
|Certification period||48 months|
|Provider name||Bupa Care Services NZ Limited|
|Street address||Level 2 109 Carlton Grove Road Newmarket Auckland 1023|
|Post address||PO Box 113054 Newmarket Auckland 1149|
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: 08 October 2019
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code.||Of the three complaints followed up in their entirety, the following was evidenced; (i). Two of three did not have an acknowledgement of the complaint. (ii) One complaint that included an acknowledgment, was not within timeframes. (ii). Two of three complaints did not evidence follow-up such as an action plan or review of issues raised through meeting minutes.||(i). Ensure that complaints are acknowledged as per Bupa policy. (ii). Ensure that complaint documentation is within timeframes set by Bupa policy. (iii). Ensure that issues raised through complaints have a documented follow-up process to enable service improvement.||PA Low||Reporting Complete||03/06/2020|
|Key components of service delivery shall be explicitly linked to the quality management system.||The designated restraint meeting does not document the discussion and evaluation of restraint use. Only numbers and names of residents who are restrained are documented. The correct use of restraint was noted to be an issue at this audit and minutes of meetings did not document this had been noted and reviewed. The RN and quality meetings are the designated IC meeting, five of seven months of the quality meetings and all of the RN meetings did not document review and discussion of infection c… (this text has been trimmed due to space limits).||Ensure that the restraint meeting minutes evidence review and evaluation of restraint use. Ensure that infection control quality data and clinical outcomes are documented as reviewed, evaluated and discussed||PA Low||Reporting Complete||03/06/2020|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Internal audits did not document an action plan where shortfalls had been noted, including; the incident internal audit - April, care planning audit - May, medication audit, multi-disciplinary review audit and weight audit – August.||Ensure that action plans are documented where a shortfall is identified following internal audits.||PA Low||Reporting Complete||03/06/2020|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||i) No individual triggers or resident specific de-escalation techniques were identified in two of two dementia files. ii) Three of three residents were currently on a T-belt restraint. The care plan did not document what to do if the resident is restless during the night. The monitoring chart indicated the residents were sitting in a lazy boy chair and restrained overnight.||Ensure all care interventions are documented in the care plan.||PA Moderate||Reporting Complete||03/06/2020|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i) There was no turning chart in place as stipulated in the LTCP for a hospital resident with a current pressure injury. ii) A hospital level resident on continuous oxygen had no oxygen monitoring chart in place as per policy. iii) One fluid balance chart was not consistently recorded for one hospital level resident. iv) Three of three files of residents that utilise restraints do not document monitoring during the day.||Ensure all monitoring charts are fully completed as instructed in the care plans.||PA Low||Reporting Complete||03/06/2020|
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: 08 October 2019
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Partial Provisional Audit