Bethany Hill Dementia Care
Profile & contact details
|Premises name||Bethany Hill Dementia Care|
|Address||582 Leigh Road Whangateau 0985|
|Service types||Dementia care|
|Certification/licence name||Agape Care Warkworth Limited - Bethany Hill Dementia Care|
|Current auditor||The DAA Group Limited|
|End date of current certificate/licence||07 March 2021|
|Certification period||36 months|
|Provider name||Agape Care Warkworth Limited|
|Street address||582 Leigh Road Whangateau 0985|
|Post address||52A King George Avenue Espom Auckland 1023|
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: 08 October 2109
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||A staff member with a current first aid certificate is not always rostered on duty. Two health care assistants employed more than 18 months have not yet completed an industry approved qualification in dementia care. Records are not available to demonstrate a fire drill has been completed in the last 12 months. The process of monitoring and follow-up that applicable staff are completing required education is not consistently occurring in a timely manner.||There is at least one staff member on duty with a current first aid certificate. Applicable care staff complete an industry approved qualification in dementia care within eighteen months of employment. Provide regular fire evacuation training for staff and retain records. Monitor that staff are completing ongoing education in a timely manner.||PA Moderate||In Progress|
|The appointment of appropriate service providers to safely meet the needs of consumers.||(i)There was no evidence in the five files of police checking; (ii) three files had no current performance appraisals (the other two staff member are recently employed and therefore not due); (iii) there was no evidence in two files of reference checking; (iv) there was no evidence in two files of position descriptions.||Human resources processes are to be completed for all staff including police checking, reference checks, position descriptions and performance appraisals.||PA Moderate||Reporting Complete||06/08/2018|
|The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.||(i)The shower floor in the Takahe wing slopes towards to the door, and as a result water is damaging the door and potentially the floor and walls. (ii)The flower gardens surrounding the facility are overgrown and need weeding. (iii) External areas of the building have paint worn off, the roofing is showing rust and there is moss on the south walls.||(i)Provide a timeframe for replacing the shower door and rectifying the way the water flows. (ii)Weed and maintain the flower gardens. (iii)Ensure the exterior of the facility is maintained.||PA Moderate||Reporting Complete||06/08/2018|
|The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code.||There was no written documentation available for any of the complaints entered in the complaints register to evidence compliance with Right 10 of the Code. The register does not provide for entering timeframes relating to responding to complainants.||Provide documented evidence that all complaints received meet Right 10 of the Code.||PA Low||Reporting Complete||01/10/2018|
|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.||An ‘audit’ (count) of the controlled drugs is conducted monthly, rather than the required weekly. There has not been a required six-monthly controlled drug stocktake in the last year.||Ensure a count of controlled drugs is undertaken weekly and that a controlled drug stock take is undertaken six monthly.||PA Low||Reporting Complete||01/10/2018|
|Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.||The summer menu is now in use and this has not been reviewed by a qualified dietitian.||Ensure the summer menu is reviewed by a qualified dietitian.||PA Low||Reporting Complete||18/12/2018|
|Consumers are provided with safe and accessible external areas that meet their needs.||(i)The concrete path leading from Hi Hi wing to the outside is broken, uneven and sloping. (ii)The retaining wall near the raised gardens is approximately 1.5 metres high and can easily be accessed by residents, who could walk along the top of the wall and fall on to the concrete below.||(i)Provide a timeframe for repair of the concrete path (ii)Provide a timeframe for making the area leading to the top of the retaining wall safe.||PA Moderate||Reporting Complete||18/12/2018|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||The RN/ infection control coordinator has not undertaken ongoing education specific to infection prevention and control. The Activities Officer has not received training to support her to assess, implement and evaluate the activities programme.||Ensure training is provided to the RN to assist her in her role as ICN. Ensure the Activities Officer has the knowledge and skills to ensure she can provide assessment, implementation and evaluation of the activities programme.||PA Low||Reporting Complete||17/06/2019|
|The service develops and implements policies and procedures that are aligned with current good practice and service delivery, meet the requirements of legislation, and are reviewed at regular intervals as defined by policy.||Approximately three quarters of the policies and procedures have not been reviewed and updated. The medicine policy has sections that are not applicable to dementia level care.||All policies and procedures are reviewed and updated, including reference to current legislation, as per the timeframe set out in the policy.||PA Low||Reporting Complete||14/08/2019|
|Service providers responsible for medicine management are competent to perform the function for each stage they manage.||One of two staff members observed administering medicines did not administer medicines in a safe manner. Records were not available to demonstrate this staff member had completed Bethany Hill Dementia Care’s medicine competency assessment. Records were not available to demonstrate that three other HCA staff who administer medicines have completed the medicine competency assessment training programme. The medicine competency assessment records for four other staff were incomplete and/or have not … (this text has been trimmed due to space limits).||Ensure medicines are administered in a safe manner and by staff who have completed the organisation’s medicine competency assessment programme. Retain appropriately detailed/completed records of these assessments.||PA High||Reporting Complete||16/12/2019|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||The complaints register does not include details of all complaints received. Records are not available to consistently demonstrate that all complaints have been acknowledged, investigated and responded to in a timely manner.||Ensure the complaints register includes details of all complaints and that records are retained to demonstrate that all complaints have been investigated and responded to within timeframes that align with the Code.||PA Moderate||Reporting Complete||03/03/2020|
|Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.||A fire extinguisher is being moved about within the facility.||Ensure the fire extinguishers are appropriately secure and accessible by staff in agreed locations in the event of an emergency.||PA Moderate||Reporting Complete||03/03/2020|
|Consumers are provided with safe and accessible external areas that meet their needs.||The retaining wall near the raised garden is approximately 1.5 metres high and can easily be accessed by residents, who could get access to walk along the top of the wall and fall onto the concrete below. A resident was observed walking up on the path near this area, after climbing over one of the internal gates. Residents were observed mobilising in an area that is intended for staff access only – the residents had exited out of the door opposite the ‘top dining room’. The residents are unable … (this text has been trimmed due to space limits).||Make the area leading to the top of the retaining wall safe. Ensure residents mobilise within the external areas authorised for their use.||PA High||Reporting Complete||04/03/2020|
|The appointment of appropriate service providers to safely meet the needs of consumers.||Records are not available to demonstrate the recruitment process consistently includes interviews, conducting reference checks and police vetting including for three staff employed since the last audit. Job descriptions are also missing from at least three staff files sampled. Annual performance appraisals present in two staff files were not dated and/or signed. Appraisals were overdue in seven of seven staff files reviewed for staff employed more than 12 months.||Human resources appointment processes are consistently completed for all staff including police checking, reference checks, position descriptions and annual performance appraisals and records are retained.||PA High||Reporting Complete||04/03/2020|
|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.||Medicine errors / incidents discussed during the last three staff meetings as detailed in meeting minutes sighted have not been included in the incident data sighted for the period April 2019 to August 2019. While some adverse events / incidents sampled contained details of investigation and follow-up, this was not consistent.||Ensure all adverse, unplanned and untoward events including service shortfalls are documented as incidents. Investigate and follow-up all reported events/incidents in a timely manner.||PA High||Reporting Complete||04/03/2020|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Staff reported they were provided with an orientation relevant to their role. However, records were not available to demonstrate this had been completed in four out of ten staff files sampled.||Ensure staff are provided with an orientation relevant to their role and records are consistently retained to demonstrate this.||PA Moderate||Reporting Complete||04/05/2020|
|The organisation is managed by a suitably qualified and/or experienced person with authority, accountability, and responsibility for the provision of services.||The facility manager is the owner and manager of two aged related residential care services. While the facility manager/owner is on site at Bethany Hill Dementia Care at least two and normally three days a week, this is insufficient time to complete all activities required by the facility manager. Records are not available to demonstrate that the facility manager/owner has attended more than eight hours of education per annum as required to meet the provider’s contract with Waitemata District He… (this text has been trimmed due to space limits).||Ensure the facility manager roles and responsibilities can be effectively undertaken. Maintain records to demonstrate the facility manager/owner has attended at least eight hours of education per annum as required to meet the providers contract with WDHB.||PA Moderate||Reporting Complete||02/06/2020|
|There is a document control system to manage the policies and procedures. This system shall ensure documents are approved, up to date, available to service providers and managed to preclude the use of obsolete documents.||Updated policies and procedures have been obtained from an external consultant. However, only the updated clinical policies have been printed and made available for staff. The copies of the printed policies/procedures available for staff reference, including the cleaning manual, laundry manual, food services manual and emergency procedures are overdue for review.||Ensure current policies and procedures are available for staff, and that document control processes are consistently implemented to remove out of date policy / procedure documents from use.||PA Moderate||Reporting Complete||02/06/2020|
|Key components of service delivery shall be explicitly linked to the quality management system.||The meeting minutes for one out of five staff meetings sighted explicitly includes discussions on restraint minimisation. The infection surveillance results (numbers and trends over time) reported to be discussed at staff meetings are not included in any of the five meeting minutes sighted.||Ensure key components of service delivery are explicitly linked to the quality and risk programme including infection prevention and control and restraint minimisation.||PA Low||Reporting Complete||02/06/2020|
|A process to measure achievement against the quality and risk management plan is implemented.||Internal audits and surveys have not been undertaken since May 2018.||Undertake internal audits and satisfaction surveys as scheduled in the internal audit schedule.||PA Moderate||Reporting Complete||02/06/2020|
|The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.||The facility manager/owner advised three essential notifications have been made since the last audit. Records were not available in relation these.||Ensure essential notifications are made when required, and records are retained of these communications.||PA Low||Reporting Complete||02/06/2020|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Corrective action plans have not been consistently documented when areas for improvement are identified / required. This included in response to adverse events / incidents and internal audits (when completed). Required actions are not always undertaken in a timely manner or monitored for effectiveness.||Ensure corrective action plans are developed when areas for improvement are identified, including detail of the improvements required, by whom and timeframes. Implement a process to monitor that required actions are undertaken and are evaluated for effectiveness.||PA High||Reporting Complete||01/07/2020|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||The service does not have a food control plan or date as yet for the verification audit to occur.||Develop a food control plan and have a verification audit of the food services to meet legislative requirements.||PA Low||Reporting Complete||01/07/2020|
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: 08 October 2109
Audit type:Surveillance Audit
- Bethany Hill Dementia Care - Oct 2109 (docx, 43.13 KB)
- Bethany Hill Dementia Care - Oct 2109 (pdf, 171.17 KB)
Audit type:Certification Audit
- Bethany Hill Dementia Care - Jan 2018 (docx, 53.38 KB)
- Bethany Hill Dementia Care - Jan 2018 (pdf, 185.23 KB)
Audit type:Provisional Audit