Awanui Rest Home
Profile & contact details
|Premises name||Awanui Rest Home|
|Address||454 Panama Road Mount Wellington Auckland 1062|
|Service types||Dementia care|
|Certification/licence name||MA Healthcare Group Limited - Awanui Rest Home|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||29 June 2022|
|Certification period||36 months|
|Provider name||MA HealthCare Group Limited|
|Street address||446A Panama Road Mount Wellington Auckland 1062|
|Post address||PO Box 68744 Wellesley Street Auckland 1141|
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: 25 February 2021
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.||The registered nurse has not documented a weekly progress note or review in each resident’s file or documented changes in state for the resident when these have occurred||Ensure that the registered nurse completes a record of care for each resident at least weekly and as changes occur||PA Low||Reporting Complete||29/11/2021|
|Service providers responsible for medicine management are competent to perform the function for each stage they manage.||Eleven senior HCAs administering medications do not have medication competencies.||Ensure all HCAs administering medications have completed medication competencies.||PA Moderate||Reporting Complete||02/09/2019|
|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.||Eye drops are not dated when opened.||Date all eye drops when opened.||PA Low||Reporting Complete||25/11/2019|
|Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.||(i). There are only two staff who have completed first aid training and a review of rosters confirmed that there is not a first aider on duty at all times. (ii). Emergency drills are not held at least six monthly.||(i). Ensure that there is at least one staff member with a first aid certificate on duty at all times. (ii). Ensure that emergency drills are held for staff at least six monthly.||PA Moderate||Reporting Complete||25/11/2019|
|The service is able to demonstrate that written consent is obtained where required.||(i) Three out of eight residents do not have a signed consent form. (ii). One resident admitted in October 2018 has no EPOA.||(i). Ensure all residents have a consent form. (ii). Ensure all residents have an EPOA.||PA Moderate||Reporting Complete||16/03/2020|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||(i). Four of seven staff records reviewed had an outdated performance appraisal last completed over a year ago. (ii). Five of the fourteen healthcare assistants who work in the service have not completed dementia training as per contractual specifications and are not enrolled in training.||(i). Ensure that staff have an annual performance appraisal completed. (ii). Ensure that all staff who have been employed in the service for longer than six months are enrolled in or have completed dementia training against set standards.||PA Moderate||Reporting Complete||16/03/2020|
|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.||Evaluation of each care plan has not occurred.||Ensure there is a documented evaluation of each care plan||PA Low||In Progress|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||Six of the thirteen healthcare assistants who work in the dementia unit have not completed appropriate training in dementia standards and they are not enrolled in the programme. The shortfall identified at the certification audit remains, however the rating and timeframe remains the same as training has at times been delayed because of Covid-19.||Ensure that all staff who have been employed in the service for longer than six months are enrolled in or have completed dementia training against set standards.||PA Moderate||In Progress|
|The service is able to demonstrate that written consent is obtained where required.||(i) Two out five resident records did not have a signed consent form. (ii) Two out of five resident files did not include evidence of an EPOA.||(i) Ensure all residents have a consent form signed. (ii) Ensure all residents have an EPOA.||PA Moderate||In Progress|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||Actual temperatures for the freezers are not recorded.||Record actual temperatures of each freezer and resolve any corrective actions if these are identified.||PA Low||In Progress|
|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.||Assessments, care plans and evaluations/reviews of care plans are not always consistently completed in a timely manner as follows: (i) One resident file did not include an initial interRAI assessment. (ii) Three of five resident files did not include a current interRAI (one was last completed in January 2020 and one in September 2019). (iii) One resident file did not have an initial care plan. (iv) Evaluations of the care plan were not completed six-monthly in three of four long term files. … (this text has been trimmed due to space limits).||(i)-(iv) Ensure that assessments, care plans and evaluations of care plans are consistently completed in a timely manner and as per the ARC contract.||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.||(i) Three of five care plans reviewed included a lack of documentation of interventions to address specific cares required (eg, pain in the head and neck for one resident, behavioural management for a second resident, weight loss for a third resident that had occurred when the resident was in hospital [noting that the resident had gained weight since their return although interventions were not specifically documented], and a resident with a rash on return from hospital noting that the hospital… (this text has been trimmed due to space limits).||(i) Document and update interventions to ensure that staff can consistently meet the residents assessed needs or that would contribute to meeting desired outcomes. (ii) Take neurological observations or record observations of the resident within timeframes documented in policy for a resident who has an un-witnessed fall or who hits their head.||PA Moderate||In Progress|
|Consumers have a right to full and frank information and open disclosure from service providers.||Of the 28 incident forms reviewed, 26 did not document evidence that family were informed of an incident that involved their family member.||Ensure that family are informed of an incident involving their family member.||PA Moderate||Reporting Complete||28/06/2021|
|The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.||Not all incidents that required this, and changes in management (clinical oversight) had been reported to the Ministry of Health on a Section 31 form.||Ensure that incidents that are required to be reported, and changes in management are reported to the Ministry of Health on a Section 31 form.||PA Low||Reporting Complete||28/06/2021|
|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) Eye drops are not dated when opened. (ii) The service does not provide hospital level care but has impress stock with a number of stock medicines being uses. (iii) Medicines in the kitchen fridge were not stored correctly or appropriately. (iv) A single bottle of liquid medication was used for another resident on two occasions. (v) Documentation of administration of medications for a respite resident was not appropriate with this documented only in the progress notes as being taken. … (this text has been trimmed due to space limits).||(i) Date eye drops when opened. (ii) Cease using an impress stock system of medication. (iii) Store medicines that require cold storage correctly and appropriately. (iv) Administer medicines to the person for whom it is prescribed. (v) Document administration of medications for a respite resident as per policy. (vi) Ensure staff maintain hand hygiene while administering medication. (vii) Record the ambient temperature of the room where medication is stored to ensure that it remain… (this text has been trimmed due to space limits).||PA Moderate||Reporting Complete||25/08/2021|
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: 25 February 2021
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Provisional Audit