Bethsaida Retirement Village

Profile & contact details

Premises details
Premises nameBethsaida Retirement Village
Address 66 Litchfield Street Redwoodtown Blenheim 7201
Total beds57
Service typesRest home care, Geriatric, Medical
Certification/licence details
Certification/licence nameBethsaida Trust Board Incorporated - Bethsaida Retirement Village
Current auditorThe DAA Group Limited
End date of current certificate/licence21 July 2023
Certification period48 months
Provider details
Provider nameBethsaida Trust Board Incorporated
Street address 66 Litchfield Street Redwoodtown Blenheim 7201
Post addressPO Box 333 Blenheim 7240

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: 01 June 2021

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include: (a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk; (b) A process that addresses/treats the risks associated with service provision is developed and im… (this text has been trimmed due to space limits).An organisational risk register is not available; therefore, not all actual and potential risks are being identified, monitored, analysed, evaluated and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk. An organisational risk register that identifies risks to be monitored, analysed, evaluated, and reviewed according to severity of the risk and the probability of change in the status of that risk requires development. PA LowIn Progress
A process to measure achievement against the quality and risk management plan is implemented.Reviews of the overall quality and risk management system have not occurred as per the policy. Quality review systems such as internal audits and resident/family surveys are not always occurring in a manner that contributes to quality improvement. Processes that enable measurement of achievement against the quality and risk management plan require reinstatement. PA LowIn Progress
The organisation has a quality and risk management system which is understood and implemented by service providers.Quality and risk management meetings/review processes have not all been re-established since March 2020; therefore, the documented quality and risk management system is not currently being implemented in a coordinated manner. The quality and risk management system is reinstated as per the description in the organisation’s policies and procedures. PA ModerateIn Progress
Key components of service delivery shall be explicitly linked to the quality management system.In the absence of a coordinated quality and risk management system, some key components of service delivery are not being linked into an organisational quality and risk management system. Monitoring and review of key components of service delivery, including incidents, complaints, infection control, health and safety and restraint minimisation are reported through the quality and risk management system to enable ongoing quality improvement processes to be maintained. PA LowIn 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. 

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.

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