Profile & contact details
|Premises name||Brightwater Home|
|Address||69 Brightwater Terrace Terrace End Palmerston North 4410|
|Service types||Rest home care, Geriatric, Medical, Dementia care|
|Certification/licence name||Presbyterian Support Central - Brightwater Home|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||16 August 2019|
|Certification period||36 months|
|Provider name||Presbyterian Support Central|
|Street address||3-5 George Street Thorndon Wellington 6011|
|Post address||PO Box 12706 Thorndon Wellington 6144|
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 December 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||Ensure that all complaints made have documented evidence of resolution or close off.||Ensure that all complaints made have documented evidence of resolution or close off.||PA Low||In Progress|
|Consumers who have additional or modified nutritional requirements or special diets have these needs met.||i) Three dementia residents recently admitted, did not have a nutritional profile sent to the kitchen. ii) The kitchen staff were unaware of one hospital resident with a food allergy.||i-ii) Ensure that the kitchen receives a copy of the nutritional profile for all residents and the kitchen is advised of any resident food allergies.||PA Low||Reporting Complete||18/10/2016|
|In assessing whether restraint will be used, appropriate factors are taken into consideration by a suitably skilled service provider. This shall include but is not limited to: (a) Any risks related to the use of restraint; (b) Any underlying causes for the relevant behaviour or condition if known; (c) Existing advance directives the consumer may have made; (d) Whether the consumer has been restrained in the past and, if so, an evaluation of these episodes; (e) Any history of trauma or abuse, whi… (this text has been trimmed due to space limits).||Two of five hospital restraint files reviewed did not have their restraint assessments fully documented.||Ensure that all assessment forms for residents on restraint are fully completed.||PA Low||Reporting Complete||18/10/2016|
|Each episode of restraint is documented in sufficient detail to provide an accurate account of the indication for use, intervention, duration, its outcome, and shall include but is not limited to: (a) Details of the reasons for initiating the restraint, including the desired outcome; (b) Details of alternative interventions (including de-escalation techniques where applicable) that were attempted or considered prior to the use of restraint; (c) Details of any advocacy/support offered, provided o… (this text has been trimmed due to space limits).||i) Four of five hospital residents using a restraint, and three of three residents using enablers (two hospital and one young person with disability), did not have interventions documented to manage all identified risks. ii) Five of five hospital residents using restraint did not have the required monitoring consistently documented.||i) Ensure that interventions are documented, to cover the risks associated with the use of the restraint or enablers and the residents care requirements whilst using the restraint or enabler, are fully documented. ii) Ensure that all monitoring whist using a restraint is consistently documented.||PA Moderate||Reporting Complete||18/10/2016|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||i) Three of three resident files sampled for residents in the secure dementia unit, did not have activity plans documented to cover the 24-hour period. ii) One of seven activity care-plans (hospital – young person with disability) had not been reviewed six monthly. iii) Seven of seven activity care-plans (one rest home, three hospital and three dementia) had not been evaluated against the stated activity goals. iv) One dementia activity plan had no activities documented to meet the specific… (this text has been trimmed due to space limits).||i) Ensure that all residents in the secure dementia unit have a 24-hour activity care plan documented. ii) Ensure that activity plans are reviewed at least six monthly. iii) Ensure that the activity care plan is reviewed against the stated goals. iv) Ensure that activities are planned and documented to meet the specific needs of the resident.||PA Low||Reporting Complete||18/10/2016|
|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.||Three of seven files sampled (dementia level care) had not had the InterRAI assessment reviewed six monthly.||Ensure that assessments are reviewed with a change in health condition or reviewed at least six monthly.||PA Low||Reporting Complete||18/10/2016|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||Seven out of eighteen HCAs who have been working in the secure dementia unit for more than 12 months have not completed the required dementia unit standards.||Ensure that all staff working in the secure dementia unit complete the required dementia specific training within the required timeframes.||PA Low||Reporting Complete||14/12/2016|
|All records are legible and the name and designation of the service provider is identifiable.||Seven of seven long-term care plans (one rest home, three hospital and three dementia) did not have amendments or alterations consistently dated and signed with a designation recorded.||Ensure that all amendments and alterations to the long-term care plans are consistently signed and dated with a designation documented.||PA Low||Reporting Complete||24/01/2017|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i) Two of seven care plans reviewed (one hospital, one dementia), did not include all interventions to address assessed needs. (ii) De-escalation strategies were not fully documented for one dementia resident with abusive behaviour. (iii) One dementia resident on a short-term care plan for behaviour, had not had the interventions evaluated or transferred to the long-term care plan. (iv) Monitoring records were not consistently documented for one hospital resident on two hourly turns. (v) Th… (this text has been trimmed due to space limits).||i-iii) Ensure that interventions are fully documented to meet the assessed care needs of the residents. iv) Ensure that all required monitoring is consistently documented. v) Ensure that all wound documentation is fully completed.||PA Low||Reporting Complete||24/01/2017|
|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.||i) Infection control data is recorded monthly, however month-on-month trending and analysis of this data was not consistently evidenced. ii) The surveillance data was not consistently communicated to all staff. iii) The corrective action plan developed during the norovirus outbreak in August 2015 has not yet been completed and signed out.||i-ii) Ensure that infection control data is consistently trended and analysed and the results are consistently communicated to all staff. iii) Ensure that the corrective action developed during the norovirus outbreaks is completed and signed out.||PA Low||Reporting Complete||24/01/2017|
|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).||The hazard register had not been reviewed annually. There was no documented evidence of hazard identification form for 2017 being updated on the hazard register.||Ensure that the hazard register is reviewed annually and that hazard identification forms are updated on the hazard register.||PA Low||In Progress|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||One of one resident files sampled in the dementia unit did not have a 24-hour recreational plan documented. On interview with the recreation officers and RNs, it was confirmed no residents in the dementia unit had a recreational plan for a 24-hour period.||Ensure that all residents in the dementia unit have a 24-hour recreational plan documented.||PA Moderate||In Progress|
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: 01 December 2017
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit