Cairnfield House

Profile & contact details

Premises details
Premises nameCairnfield House
Address 60 Jack Street Otangarei Whangarei 0112
Total beds87
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 2020
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: 16 January 2018

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 LowIn Progress
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.i) Attendance at in-service training is consistently below 50%. Where attendance has been low at mandatory training (fire safety, manual handling, and code of rights) there is no process in place for staff who do not attend. ii) Five of seven staff who were due for an annual performance review, had not had a performance review completed. i) Ensure that there is a process in place for staff who do not attend mandatory training. ii) Ensure that performance reviews are completed for all staff at least annually. PA LowIn Progress
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.Accident and incident forms had not been completed for the two residents (one rest home and one hospital) with current pressure injuries. Ensure that accident and incident forms are completed for all adverse events. PA LowReporting Complete19/12/2017
The facilitation of safe self-administration of medicines by consumers where appropriate.i) Two of two hospital residents self-medicating had not had the required self-medication competencies documented. ii) There was no documented evidence that a registered nurse was checking that the residents who were self-medicating were taking their medication as prescribed. i) Ensure residents who are self-medicating have medication competencies completed. ii) Ensure that registered nurse checks on each shift that the resident is taking the medication as prescribed. PA LowReporting Complete19/12/2017
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.Two of four residents (one hospital and one rest home) following unwitnessed fall did not have neurological observations documented. Ensure that the required monitoring of residents is completed as per the organisational policy for residents following an unwitnessed fall. PA LowReporting Complete19/12/2017
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 trial fire evacuation of the new area has yet to be completed. Conduct a trial evacuation drill covering the new areas and document the event PA LowIn Progress
Consumers are provided with safe and accessible external areas that meet their needs.The external areas within the new wing have yet to be landscaped. Secure balconies yet to be in place for higher level resident rooms with external access doors Ensure landscaping is completed at the end of the building programme and secure balconies in place prior to occupancy. PA LowIn Progress
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.I) Attendance at in-service training is consistently below 50%. Where attendance has been low at mandatory training, a process is being implemented to ensure information through questionnaires and follow up but this is not fully implemented yet. ii) Three of five staff who were due for an annual performance review, had not had a performance review completed. i) Ensure that there is a process in place for staff who do not attend mandatory training. ii) Ensure that performance reviews are completed for all staff at least annually. PA LowIn Progress
Where required by legislation there is an approved evacuation plan.The current evacuation plan has not been amended to include the new wing. (i)Ensure the evacuation plan has been amended to include the extensions and provide evidence that an application has been lodged with the NZ Fire Service prior to occupancy; (2) Obtain an approved fire evacuation plan. PA LowIn Progress
The facilitation of safe self-administration of medicines by consumers where appropriate.Ensure there is a documented process of RNs checking self-administration of medicines and that residents sign the assessment / consent. Ensure there is a documented process of RNs checking self-administration of medicines and that residents sign the assessment / consent. PA LowIn Progress
An appropriate 'call system' is available to summon assistance when required.There is a call bell system in the process of being installed in the new wing. Ensure the call bell system is operational. PA LowIn Progress
All buildings, plant, and equipment comply with legislation.The new building is in the process of being completed and therefore a certificate of public use has yet to be completed. Ensure a certificate of public use is obtained and evidence provided to the DHB and HealthCERT. 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.InterRAI assessments were not completed at six monthly intervals for three resident files reviewed. Ensure interRAI time frames are met for six monthly ongoing assessments PA ModerateIn Progress
The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.The rooms are still in the process of being furbished and handrails are not yet in place. Ensure handrails are in place in bathrooms and ensuites. PA LowIn Progress
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.Five of five incidents reviewed for unwitnessed falls all had neurological observations documented, however none had been continued for 24 hours, three were hourly for three hours, two were three to four hourly for five hours and all were documented at varying time frames following this with time frames varying from three to eight hours. Ensure that the required monitoring of residents is completed as per the organisational policy for residents following an unwitnessed fall. PA ModerateIn 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.(i) InterRAI assessments were not completed within 21 days for two of five hospital residents and one of four rest home resident files reviewed (all residents had resided at the facility for longer than three weeks. (ii) InterRAI assessments were not completed at six monthly intervals for two of four rest home resident files reviewed. Ensure that contractual timeframes around resident InterRAI assessments are met. PA LowReporting Complete16/02/2018

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.

Audit reports

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

Audit date: 13 August 2014

Audit type:Surveillance Audit

Audit date: 30 January 2014

Audit type:Partial Provisional Audit

Audit date: 14 August 2013

Audit type:Certification Audit

Audit date: 29 April 2013

Audit type:Surveillance Audit

Audit date: 07 September 2012

Audit type:Provisional Audit

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