Ascot Care Home
Profile & contact details
|Premises name||Ascot Care Home|
|Address||149 Racecourse Road Glengarry Invercargill 9810|
|Service types||Geriatric, Medical, Physical, Dementia care, Rest home care|
|Certification/licence name||Bupa Care Services NZ Limited - Ascot Care Home|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||04 December 2023|
|Certification period||24 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: 21 September 2021
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|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.||i) The long term care plan for one hospital resident had not been reviewed or amended following a change in level of care from rest home to hospital level. ii) Long term care plan evaluations did not indicate the degree to which goals had been met for one dementia resident, and one hospital level resident. iii) Long term care plan evaluations had been conducted before the interRAI reassessment process, therefore had not informed the care planning evaluation for one dementia, two hospital and o… (this text has been trimmed due to space limits).||i) Ensure that care plans are reviewed and amended when required to reflect all current care requirements. ii) Ensure that care plan evaluations address each aspect of the care plan. iii) Ensure that long term care plan evaluations are conducted after interRAI reassessments in order to inform the care plan.||PA Low||Reporting Complete||19/04/2022|
|The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.||i) Caregiving staff commencing their shifts are not always provided with a verbal handover of resident information. ii) Progress notes reviewed for three rest home and three dementia residents do not evidence regular reviews by a registered nurse.||i) Ensure that all clinical staff receive a handover prior to commencing their shifts. ii) Provide evidence that registered nurses are reviewing progress notes for rest home and dementia unit residents.||PA Moderate||Reporting Complete||19/01/2022|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||i) Mandatory (annual) training is not being completed as per the Bupa training calendar. For those in services that take place, staff attendance is very low (below 50%). ii) One caregiver who has been employed to work in the dementia unit for over 18 months has not completed the required dementia standards.||i) Ensure the staff education and training programme is implemented as per the Bupa education and training calendar, and that staff attend all mandatory training. ii) Ensure all staff who work in the dementia unit complete the four required dementia standards within 18 months.||PA Moderate||Reporting Complete||01/03/2022|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||At the time of the audit, there were six full-time RN vacancies, two full-time EN vacancies, six full-time and four part-time caregiver vacancies. Recently six new care staff were employed. Of the six, five did not turn up for work. The remaining new care staff came for only two shifts and then failed to return. Due to the high number of staff vacancies, a staff roster cannot be built to meet staffing requirements and is highly dependent on casual staff and staff working extra shifts in orde… (this text has been trimmed due to space limits).||Ensure staffing levels are maintained to provide safe services to residents.||PA Moderate||Reporting Complete||01/03/2022|
|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.||Weekly checks of controlled drug medications have not been conducted.||Provide evidence that regular weekly controlled drug register checks are conducted.||PA Moderate||Reporting Complete||01/03/2022|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||i) A selection of quality data that is being collected and collated (eg, falls, skin tears, bruising) is not regularly trended, and analysed (evidenced once over twelve months). ii) Staff are not regularly kept informed regarding quality results (eg, the frequency of adverse events and internal audits completed each month and their results).||i) Ensure data that is collected is consistently trended and analysed. ii) Ensure quality data and internal audit results are communicated to staff.||PA Low||Reporting Complete||19/04/2022|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Six of fourteen internal audits reviewed for 2021 were missing evidence of corrective actions being implemented (eg, laundry services, medication management, resident reviews, environment, cleaning, RiskMan).||Ensure corrective actions are reflected as being implemented/signed off to indicate that they have been addressed.||PA Moderate||Reporting Complete||19/04/2022|
|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.||Thirty-three incident/accident reports (July and August 2021) are awaiting sign-off by the clinical manager.||Ensure each adverse event includes a timely review by the clinical manager.||PA Low||Reporting Complete||19/04/2022|
|Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is undertaken by suitably qualified and/or experienced service providers who are competent to perform the function.||Enrolled nurses complete care plans for rest home and dementia residents. There is no evidence of registered nurse review and sign off in three rest home and one of three dementia files reviewed.||Provide evidence that registered nurses have signed off care plans that have been completed by enrolled nurses.||PA Low||Reporting Complete||19/04/2022|
|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) InterRAI assessments have not been completed within 21 days of admission for two rest home residents; ii) long term care plans were not completed within 21 days of admission for one hospital and one dementia level resident; iii) six monthly care plan evaluations were not completed on time for one hospital and one dementia level resident.||i)-iii) Ensure that all aspects of assessments, care planning and evaluations are completed within the expected timeframes.||PA Low||Reporting Complete||19/04/2022|
|Each episode of restraint is documented in sufficient detail to provide an accurate account of the indication for use, intervention, duration, its outcome, and shall include but is not limited to: (a) Details of the reasons for initiating the restraint, including the desired outcome; (b) Details of alternative interventions (including de-escalation techniques where applicable) that were attempted or considered prior to the use of restraint; (c) Details of any advocacy/support offered, provided o… (this text has been trimmed due to space limits).||One resident file reviewed included the use of a t-belt as a restraint and bedrails as an enabler. The restraint coordinator confirmed that this resident is unable to voluntarily request the bedrail to be released and was put in place as per family request. Use of the bedrails was assessed as a restraint/enabler with risks documented. The care plan identified that bedrails were required to be raised when the resident was in bed. Monitoring of this restraint took place only once per shift and… (this text has been trimmed due to space limits).||Ensure that the use of bedrails as a restraint is regularly monitored as per Bupa restraint policy.||PA Low||Reporting Complete||19/04/2022|
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: 21 September 2021
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit