Ashlea Grove Rest Home

Profile & contact details

Premises details
Premises nameAshlea Grove Rest Home
Address 35 Centennial Avenue Milton 9220
Total beds37
Service typesDementia care, Rest home care
Certification/licence details
Certification/licence nameElsdon Enterprises Limited - Ashlea Grove Rest Home
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence02 October 2020
Certification period36 months
Provider details
Provider nameElsdon Enterprises Limited
Street address 1 Taaffes Glen Road Rangiora 7472
Post address1 Taafes Glen Road RD 2 Rangiora 7472

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: 16 April 2019

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
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.Twelve incident forms were reviewed in total. Four incident forms were reviewed for resident falls with a head injury. The neurological observations forms completed were not all fully completed. Ensure that neurological observations are fully completed for any resident with a potential head injury. PA LowReporting Complete17/01/2018
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 evidence of gaps in two signing sheets (one eye drops) and an incorrect signing in one other (eye drops). (ii) Staff were observed not following policy and procedures during medication administration. (i) Ensure all medications are administered as prescribed. (ii) Ensure that medication administration policies and procedures are implemented by staff. PA ModerateReporting Complete17/01/2018
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.Three of six files reviewed (two rest home and one dementia) admitted after 1 July 2015, did not have an initial interRAI assessment completed within 21 days. Ensure an interRAI assessment is completed for all new residents within 21 days and this informs the LTCP. PA LowReporting Complete17/01/2018
The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.All six files sampled had significant periods (some of over four weeks) where there was no RN documentation in the progress note. Ensure that all residents are reviewed regularly by a RN and that this is documented. PA LowReporting Complete17/01/2018
The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.Hot water temperatures are consistently above 45 degrees Celsius. On the day of audit this was addressed and the temperatures were below 45 degrees Ensure all hot water temperatures are maintained at 45 degrees or lower. PA ModerateReporting Complete17/01/2018

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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