Profile & contact details
|Address||27 McLean Street Tauranga 3110|
|Service types||Geriatric, Medical, Rest home care|
|Certification/licence name||Aspen Lifecare Limited - Aspen|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||23 September 2020|
|Certification period||24 months|
|Provider name||Aspen Lifecare Limited|
|Street address||27 McLean Street Tauranga 3110|
|Post address||PO Box 915 Tauranga 3140|
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: 27 June 2019
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|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 respite rest home admission initial assessments and care plan had not been completed for the current admission. ii) One rest home admission did not have initial long-term care plan completed within 21 days.||Ensure that all aspects of assessments and care plans are completed within the required timeframes.||PA Moderate||Reporting Complete||01/10/2018|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Interventions had not been fully documented in the long-term care plan for; i) One rest home resident at risk of wandering and also using nicotine patches ii) One rest home resident with shortness of breath and recent significant weight loss iii) One rest home resident long-term care plan had not been amended following a change in mobility and had no interventions documented for management of diabetes. iv) One insulin dependent hospital resident did not include interventions to guide care sta… (this text has been trimmed due to space limits).||Ensure each residents care plan contains interventions to meet all assessed needs.||PA Moderate||Reporting Complete||01/10/2018|
|The service is able to demonstrate that written consent is obtained where required.||Four of seven resident files (all rest home) did not have a current signed admission agreement on file.||Ensure all residents have signed admission agreements on file.||PA Low||Reporting Complete||12/11/2018|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||i) There was no documented evidence that meeting minutes included discussion around quality data trends analysis and what actions were required by staff. ii) There is an annual internal audit calendar in place, however 41 of 51 internal audits for 2017 and 2018 year-to-date have not been completed as per the required schedule. Corrective actions required for the internal audits completed that were not compliant, have not been fully completed or signed off.||i) Ensure that staff meeting minutes include discussion of quality data trends analysis and actions required, if any. ii) Ensure that all internal audits are completed as per the required schedule.||PA Low||Reporting Complete||12/11/2018|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||Not all mandatory education/training has been completed within the required two-year period. Education not completed includes; cultural awareness/safety, abuse and neglect, code of rights, advocacy, open disclosure, complaints, spirituality, nutrition/hydration, pain management and care planning.||Ensure that the infection control coordinator undertakes specific infection control training Ensure that the annual education planner is implemented, and education is provided to cover all mandatory two-yearly training requirements.||PA Low||Reporting Complete||12/11/2018|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||A sample of 20 wounds were reviewed as part of this audit. (i) The following shortfalls were identified around wound documentation; a) seven of 20 wound management plans included multiple wounds on the same assessment and management plan; this was addressed during the audit; b) eight of 20 wounds plans with deterioration or malodorous discharge did not evidence input from the GP or wound specialists; c) four initial wound assessments did not fully describe the wound; d) twelve of 20 wound man… (this text has been trimmed due to space limits).||(i)Ensure GP or specialist input is involved in wound care where wounds are deteriorating; Ensure all wounds have a documented assessment, management plan and that the dressing changes follow the documented plan. ii) Ensure that neurological observations are completed as per protocol for any unwitnessed falls or any known head injury.||PA Moderate||Reporting Complete||12/11/2018|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||Two of seven residents (respite and long-term chronic health) do not have a documented assessment or an activities plan.||Ensure all residents have a documented assessment and plan.||PA Low||Reporting Complete||12/11/2018|
|Infection control education is provided by a suitably qualified person who maintains their knowledge of current practice.||The infection control coordinator has not completed specific infection control education since being in the role||Ensure that the infection control coordinator undertakes specific infection control training||PA Low||Reporting Complete||12/11/2018|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||One of five staff files reviewed evidenced an orientation programme that was partially completed, and four staff files failed to indicate that staff had completed their orientation programme.||Ensure that there is documented evidence to confirm staff have completed an orientation programme.||PA Moderate||In Progress|
|Service providers responsible for medicine management are competent to perform the function for each stage they manage.||Staff who administer medications did not all have up-to-date medication competencies. Seven RN medication competencies were last completed in Feb 2018.||Ensure staff competencies are up to date||PA Moderate||In Progress|
|The facilitation of safe self-administration of medicines by consumers where appropriate.||Two residents who self-administer medications did not store medications in a lockable area in their rooms due to the large size of the bottle.||Ensure the residents who self-administer secure their medications in a lockable area.||PA Low||In Progress|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||i) The respite resident’s care plan was not fully completed. ii) One rest home resident with seizures did not have recognition and interventions documented. iii) Two short-term care plans for an infection did not document interventions, only the administration of antibiotics.||Ensure each residents care plan includes interventions to meet all assessed needs.||PA Moderate||In Progress|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||One hospital level resident with a history of wandering did not have all checks documented. A location tracker was documented as in place in the care plan but was not in use (due to repairs).||Ensure that all monitoring is documented as occurring as per care plan||PA Low||In Progress|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Only certain aspects of an internal audit programme have been implemented. There is no internal audit schedule and no service delivery internal audits are completed.||Ensure an internal audit programme is implemented that monitors all aspects of the service.||PA Moderate||In Progress|
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: 27 June 2019
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Provisional Audit