Cairnfield House

Profile & contact details

Premises details
Premises nameCairnfield House
Address 60 Jack Street Otangarei Whangarei 0112
Total beds88
Service typesRest home care, Geriatric, Medical
Certification/licence details
Certification/licence nameAtivas Limited - Cairnfield House
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence04 October 2023
Certification period36 months
Provider details
Provider nameAtivas Limited
Street address 52-60 Jack Street Otangarei Whangarei 0112
Post addressPO Box 1478 Whangarei Whangarei 0110

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: 12 January 2022

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.Where quality data collected indicated areas requiring improvements (examples include infections, falls, lacerations, fire safety and resident care plans), corrective action plans were not consistently documented. Where actions are documented they have not consistently been reviewed and signed out once completed. Ensure that all corrective action plans are documented, reviewed, and signed out once completed. PA LowReporting Complete15/03/2021
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).One of the two files reviewed did not include documentation of an assessment and neither file reviewed included an assessment of the risks related to the use of bedrails used as a restraint. Document a comprehensive assessment for any resident using restraint and include an assessment of any risks related to the use of the restraint. PA LowReporting Complete15/03/2021
Approved restraint is only applied as a last resort, with the least amount of force, after alternative interventions have been considered or attempted and determined inadequate. The decision to approve restraint for a consumer should be made: (a) Only as a last resort to maintain the safety of consumers, service providers or others; (b) Following appropriate planning and preparation; (c) By the most appropriate health professional; (d) When the environment is appropriate and safe for successful … (this text has been trimmed due to space limits).One of the two files reviewed where restraint was used did not have strategies or interventions detailed in the long-term care plan. Ensure that the long-term care plan documents strategies and interventions relevant to the assessment. PA LowReporting Complete15/03/2021
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).The two records reviewed did not include documentation in sufficient detail to provide an accurate account of the indication for use, intervention, duration, and its outcome as per 2.2.3.4. One of the two files reviewed where restraint was used did not include documentation of the frequency of monitoring of restraint when this was in use. Monitoring of the restraint for one resident was not as per that documented in the long-term care plan. Ensure that documentation for any resident using restraint is completed in sufficient detail to provide an accurate account of the indication for use, intervention, duration, and its outcome as per 2.2.3.4. Ensure that monitoring requirements are documented in the long-term care plan with these updated as changes occur. PA LowReporting Complete15/03/2021
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.Five of five unwitnessed falls reviewed showed neurological observations were not completed according to policy. Ensure all neurological observations are fully completed in a timely manner and according to policy. PA ModerateIn Progress
Service providers responsible for medicine management are competent to perform the function for each stage they manage.Six of seven registered nurses (including clinical manager), two of three enrolled nurses, and two of four HCAs who administer medications did not have a current medication competency. Ensure all staff who administer medication have a current medication competency. PA ModerateIn Progress
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Six of six staff files did not include a current annual performance appraisal. Ensure that each staff member has an annual performance appraisal completed. PA LowIn Progress
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).Checks of the restraint when in use was not documented as per the care plan on the electronic resident management system. Ensure that checks of a restraint are documented to evidence that these have been completed as per requirements documented in the long-term care plan. PA LowIn Progress
All buildings, plant, and equipment comply with legislation.Hot water temperature monitoring has not taken place since May 2020. Ensure hot water temperature monitoring takes place as per policy requirements. PA LowIn 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.One new interRAI assessment was not completed within the timeframes stated in policy for a hospital level resident. Three hospital level routine interRAI assessments were not completed within the timeframes stated in policy. Ensure all new interRAI assessments are completed within the required timeframes according to policy. Ensure all routine interRAI assessments are evaluated/updated within the required timeframes according to policy. PA LowIn Progress
There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.The compliment of five nurses is not sufficient to ensure that there is one registered nurse on duty 24 hours a day. Implement the plan developed by the service with support from the DHB to address the current staffing shortage and continue to try and recruit into the vacant positions. PA ModerateIn 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. 

From 1 June 2009 to 28 February 2022 rest homes were audited against the Health and Disability Services Standards NZS 8134:2008. These standards have been updated, and from 28 February 2022 rest homes are audited against Ngā Paerewa Health and Disability Services Standard NZS 8134:2021.

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 Ngā Paerewa Health and Disability Services Standard.

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 reports

Audit date: 12 January 2022

Audit type:Surveillance Audit

Audit date: 22 July 2020

Audit type:Certification Audit

Audit date: 18 March 2019

Audit type:Surveillance Audit

Audit date: 16 January 2018

Audit type:Partial Provisional Audit

Audit date: 18 July 2017

Audit type:Certification Audit

Audit date: 12 August 2016

Audit type:Surveillance Audit

Audit date: 27 July 2015

Audit type:Certification Audit; Partial Provisional Audit

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