Profile & contact details
|Premises name||Bethesda Care|
|Address||743 Great South Road Wiri Auckland 2104|
|Service types||Medical, Rest home care, Geriatric|
|Certification/licence name||Bethesda Care Limited - Bethesda Care|
|Current auditor||The DAA Group Limited|
|End date of current certificate/licence||30 November 2021|
|Certification period||48 months|
|Provider name||Bethesda Care Limited|
|Street address||743 Great South Road Manukau Auckland 2241|
|Post address||PO Box 76677 Manukau City Auckland 2241|
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: 28 January 2020
|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.||While ongoing training/education is occurring, a training plan has not yet been developed for 2020. A staff member is not always on duty with a current first aid certificate. Records were not available to demonstrate that four registered nurses administering medicines have completed the medicine competency assessment programme. Annual performance appraisals of staff are not occurring. The appraisals were overdue for all sampled staff who have been employed more than 12 months.||Develop and implement a training plan. Ensure a staff member with a current first aid certificate is always on duty. Ensure records are retained that demonstrates staff independently administering medicines have been assessed as competent to do so. Undertake annual staff performance appraisals.||PA Moderate||Reporting Complete||01/07/2020|
|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.||Four of 67 residents did not have an up to date interRAI assessment.||Provide evidence that all residents have an interRAI assessment to meet contractual requirements.||PA Low||Reporting Complete||14/03/2018|
|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 dates and actions taken. Records are not available to demonstrate that complaints are consistently acknowledged, investigated and responded to within timeframes that comply with the Code, although residents and family members interviewed reported there has been a recent improvement in complaints management processes and associated communication.||Consistently document all complaints received, dates and actions taken in the complaints register. Ensure records are available to verify that all complaints are consistently acknowledged, investigated and responded to within timeframes that comply with the Code.||PA Moderate||Reporting Complete||01/07/2020|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||The quality assurance and risk management policy details the internal audits that are to be completed. A process has not been implemented to schedule when these are to occur, who is responsible, and where records are to be located/filed. Some quality improvement activities have been undertaken, for example a next of kin survey, and a staff survey. However, there is no clear process to ensure the results are reviewed and communicated/ linked to the overall quality and risk programme. A process o… (this text has been trimmed due to space limits).||Establish and implement an internal audit calendar/schedule that aligns with the requirements of the Bethesda Care quality assurance and risk management policy. Identify who is responsible for undertaking the various audits/surveys and where the resultant records are to be located. Ensure the results of audits/surveys are monitored and followed up in a timely manner. Implement a process to monitor progress for achieving the quality objectives / key performance indicators.||PA Moderate||Reporting Complete||01/07/2020|
|A process to measure achievement against the quality and risk management plan is implemented.||Incidents and infections are being reported electronically and individual reported events managed. There is currently no process to consistently evaluate themes and trends over time and to communicate these with applicable staff. Minutes are not consistently maintained or able to be located for meetings held with the health care assistants. While there are templates available to record the minutes for the various regular meetings held (health care assistants, registered nurses, health and safety… (this text has been trimmed due to space limits).||Ensure a process is implemented to evaluate the number, themes and trends of infection and adverse events/incidents. Implement a process to review and update the hazard register. Ensure meeting minutes are maintained for all meetings and consistently include information on discussions including quality and risk issues.||PA Low||Reporting Complete||01/07/2020|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||While there are some examples of timey and effective corrective action plans being developed, documented and implemented, this is not consistent for complaints, audit/satisfaction surveys and some of the issues noted in meeting minutes.||Ensure corrective actions plans are consistently documented when areas for improvement are identified as being requiring and include the actions required, timeframes, and person responsible. Ensure a process is implemented to monitor the effectiveness of actions undertaken.||PA Low||Reporting Complete||01/07/2020|
|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.||Eight out of 51 residents electronic medicine charts are overdue the three-monthly general practitioner review. The temperature of the medication refrigerator is inconsistently monitored. Six out of 12 residents’ pro re nata (PRN) medication charts sighted contained duplicate entries or the route of administration was not correctly prescribed. A resident receiving respite care did not receive one dose of medications (the medicines were still present in the blister pack), and another dose was giv… (this text has been trimmed due to space limits).||Ensure all residents’ medicines are reviewed at least three monthly by the general practitioner and that this review is noted on the medicine record. Review pro re nata medications to remove duplication and ensure the route of administration is correct. Ensure all medicines are given as prescribed or noted to be refused or withheld and appropriate records are maintained. Ensure all medication administered is appropriately documented at the time of administration. Maintain a sample signature reco… (this text has been trimmed due to space limits).||PA Moderate||Reporting Complete||01/07/2020|
|Results of surveillance, conclusions, and specific recommendations to assist in achieving infection reduction and prevention outcomes are acted upon, evaluated, and reported to relevant personnel and management in a timely manner.||Whilst individual infections are being reported and appropriately managed; there is no evidence of analysis of infection control data and including themes and trends over time or communication to relevant staff.||Ensure the results of the infection surveillance programme are regularly analysed (including themes and trends), and the results are communicated to appropriate staff.||PA Low||Reporting Complete||01/07/2020|
|The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.||Current strategic direction and goals for Bethesda Care have not been documented. The chief executive advised these will be discussed at the next executive directors board meeting.||Document the strategic direction and associated goals for Bethesda Care and implement a process for regularly reviewing progress to achieve these.||PA Low||Reporting Complete||30/09/2020|
|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.||Incidents are being reported by staff and sampled events investigated and followed up in a timely manner; however, the events are not always closed in a timely manner and the investigations, actions taken and evaluations are not always recorded/linked/cross referenced between incidents reports and residents’ clinical records as these are separate electronic systems.||Ensure a process is implemented to ensure any investigations and actions taken in response to reported adverse events are clearly linked to the adverse event report, and events are closed as and when appropriate.||PA Low||Reporting Complete||30/09/2020|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||While staff advise they are provided a comprehensive orientation programme, records were not consistently available to demonstrate that this had been completed.||Ensure records are retained to verify that staff have completed the organisation’s orientation programme within the required timeframes.||PA Low||Reporting Complete||30/09/2020|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||Rostered staffing exceeds the requirements of the safe staffing indicators and is stated to reflect a resident acuity assessment process. With the exception of the spreadsheet that details the template roster, a document detailing this staffing process/guidelines and resident assessment process was not able to be located during audit.||Ensure the documented rationale used to determine safe staffing and skill mix is available for reference when developing the staff roster.||PA Low||Reporting Complete||30/09/2020|
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: 28 January 2020
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit