Avonlea Hospital and Home

Profile & contact details

Premises details
Premises name	Avonlea Hospital and Home
Address	52 Ward Street Taumarunui 3920
Total beds	50
Service types	Rest home care, Geriatric, Medical

Certification/licence details
Certification/licence name	Avonlea Charitable Trust - Avonlea Hospital and Home
Current auditor	The DAA Group Limited
End date of current certificate/licence	02 February 2027
Certification period	36 months

Provider details
Provider name	Avonlea Charitable Trust
Street address	52 Ward Street Taumarunui 3920
Post address	PO Box 97 Taumarunui 3946

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 November 2023

Outcome required	Found at audit	Action required	Risk rating	Action status
Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services.	The service is not meeting the contractual requirement of Te Whatu Ora Waikato to provide 24/7 RN cover for hospital level care. There were a number of afternoon and night shifts that did not have a RN on duty.	Provide evidence that the service is continuing efforts to recruit RNs, analyse rosters to ascertain opportunities to better utilise RN resources, and continue to consider the number of hospital level residents receiving care so that there are sufficient RNs on site to provide clinically and culturally safe services.	PA Moderate	In Progress
Service providers shall engage with people receiving services to assess and develop their individual care or support plan in a timely manner. Whānau shall be involved when the person receiving services requests this.	The documentation in residents’ files was unable to verify residents were seen every month by the GP or every three months when deemed stable.	Provide evidence of documentation from the residents’ GP that the residents are seen monthly or three monthly when deemed stable.	PA Low	In Progress
Service providers shall evaluate progress against quality outcomes.	Progress against quality outcomes is not being evaluated as part of the internal audit process. The service is not accurately collecting internal audit information or setting up and signing off corrective actions from the process. Internal audit and adverse event information is not being reported to staff.	Provide evidence that the service understands its policy in respect of internal audit data collection and reporting. The service is to show that it accurately collects internal audit information and understands how to set up and sign off corrective actions from the process. Internal audit and adverse event information is to be reported to staff.	PA Low	In Progress
My service provider shall work in partnership with Pacific communities and organisations, within and beyond the health and disability sector, to enable better planning, support, interventions, research, and evaluation of the health and wellbeing of Pacific peoples to improve outcomes.	The service has no partnerships with Pacific communities and organisations to enable better planning, support, interventions, research, and evaluation of the health and wellbeing of Pacific peoples to improve outcomes. Given the lack of Pasifika residents in the facility the effect of this is negligible.	Provide evidence that the service has partnerships with Pacific communities and organisations to improve outcomes for Pasifika by enabling better planning, support, interventions, research, and evaluation of the health and wellbeing of Pacific peoples.	PA Negligible	In Progress
Service providers shall ensure there is a system to identify, plan, facilitate, and record ongoing learning and development for health care and support workers so that they can provide high-quality safe services.	The education programme does not cover all the requirements of the Ngā Paerewa Health and Disability Services Standard (2021) and staff have not completed the eight hours of education required by D17.7 of the service’s contract with Te Whatu Ora Waikato.	Provide evidence that the education programme has been revised to make sure all the requirements of Ngā Paerewa standard have been met. Provide evidence that staff have completed eight hours of continuing education to meet the requirements of D17.7 of the service’s contract with Te Whatu Ora Waikato.	PA Moderate	In Progress
Service providers shall ensure health care and support workers are able to provide a level of first aid and emergency treatment appropriate for the degree of risk associated with the provision of the service.	There are insufficient first aid certified staff available to provide 24/7 first aid coverage at Avonlea.	Provide evidence that supports there being sufficient first aid certified staff available to provide 24/7 first aid coverage at Avonlea.	PA Moderate	In Progress
Service providers shall conduct comprehensive reviews at least six-monthly of all restraint practices used by the service, including: (a) That a human rights-based approach underpins the review process; (b) The extent of restraint, the types of restraint being used, and any trends; (c) Mitigating and managing the risk to people and health care and support workers; (d) Progress towards eliminating restraint and development of alternatives to using restraint; (e) Adverse outcomes; (f) Compliance w… (this text has been trimmed due to space limits).	There was no evidence available to support that a comprehensive six-monthly review of restraint use had been conducted at Avonlea.	Provide evidence that that a comprehensive six-monthly review of restraint use has been conducted at Avonlea.	PA Low	In Progress
Monitoring restraint shall include people’s cultural, physical, psychological, and psychosocial needs, and shall address wairuatanga.	Monitoring restraint did not include residents’ cultural, psychological, and psychosocial needs, nor did it address wairuatanga.	Provide evidence that the monitoring of restraint includes the residents’ cultural, psychological, and psychosocial needs, and that wairuatanga is addressed.	PA Low	In Progress
Service providers shall ensure that the environment is clean and there are safe and effective cleaning processes appropriate to the size and scope of the health and disability service that shall include: (a) Methods, frequency, and materials used for cleaning processes; (b) Cleaning processes that are monitored for effectiveness and audit, and feedback on performance is provided to the cleaning team; (c) Access to designated areas for the safe and hygienic storage of cleaning equipment and chemi… (this text has been trimmed due to space limits).	The cleaning cupboard environment is in poor repair and requires refurbishment.	Provide evidence the cleaning cupboard has been refurbished.	PA Moderate	In Progress
Service providers shall ensure there are safe and effective laundry services appropriate to the size and scope of the health and disability service that include: (a) Methods, frequency, and materials used for laundry processes; (b) Laundry processes being monitored for effectiveness; (c) A clear separation between handling and storage of clean and dirty laundry; (d) Access to designated areas for the safe and hygienic storage of laundry equipment and chemicals. This shall be reflected in a writt… (this text has been trimmed due to space limits).	The laundry area is in poor repair and requires refurbishment.	Provide evidence the laundry area has been refurbished.	PA Moderate	In Progress
Each episode of restraint shall be evaluated, and service providers shall consider: (a) Time intervals between the debrief process and evaluation processes shall be determined by the nature and risk of the restraint being used; (b) The type of restraint used; (c) Whether the person’s care or support plan, and advance directives or preferences, where in place, were followed; (d) The impact the restraint had on the person. This shall inform changes to the person’s care or support plan, resulting f… (this text has been trimmed due to space limits).	None of the records of residents using restraint evidenced any evaluation of the use of the restraint.	Provide evidence that residents using restraint have had a documented evaluation of the use of the restraint.	PA Moderate	In Progress

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.

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 reports

Audit date: 21 November 2023

Audit type:Certification Audit

Audit date: 21 November 2019

Audit type:Certification Audit

Audit date: 19 July 2018

Audit type:Surveillance Audit

Audit date: 23 November 2016

Audit type:Certification Audit

Print Email Feedback