Profile & contact details
|Premises name||Camellia Resthome|
|Address||1743 Rewi Street Te Awamutu 3800|
|Service types||Rest home care|
|Certification/licence name||Level Fifty-Two Limited|
|Current auditor||HealthShare Limited|
|End date of current certificate/licence||26 October 2018|
|Certification period||36 months|
|Provider name||Level Fifty-Two Limited|
|Street address||1743 Rewi Street Te Awamutu 3800|
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: 20 February 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|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.||Not all incidents are documented using an incident form and some incidents are recorded using different mechanisms with data not currently used to improve service delivery.||Ensure that incidents are documented with data used to improve service delivery.||PA Low||Reporting Complete||29/03/2018|
|The organisation has a quality and risk management system which is understood and implemented by service providers.||A quality plan is not documented.||Document, implement and review a quality plan.||PA Low||Reporting Complete||22/12/2015|
|The facilitation of safe self-administration of medicines by consumers where appropriate.||The residents stored medicines in the top drawer of their chest of drawers. Storage of the medicines is not currently considered safe or secure.||Residents who self-administer medicines must have safe and secure storage facilities for keeping their medicines.||PA Low||Reporting Complete||22/12/2015|
|Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.||i) Four of the twelve medicines charts reviewed did not show evidence of the medicines having been reviewed within the previous three months. ii) The general practitioners block-date medicines.||i) General practitioners to sign medicines charts in evidence of three monthly reviews, ii) Entries to the medicines administration charts to be individually dated and signed by the general practitioners.||PA Low||Reporting Complete||22/12/2015|
|Advance directives that are made available to service providers are acted on where valid.||Competency to document an advance directive is not documented. The registered nurse signs for the review of an advance directive.||i) Ensure that competency to document an advance directive is completed. ii) Ensure that only the resident signs for the review of an advance directive.||PA Low||Reporting Complete||06/07/2017|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||Staffing overnight in particular does not reflect the acuity and needs of all residents.||Review the rostering of staff to ensure that staffing reflects the acuity of residents and resident need.||PA Moderate||Reporting Complete||06/07/2017|
|Service providers responsible for medicine management are competent to perform the function for each stage they manage.||The registered nurses do not have a medication competency completed but provide oversight of administration of medicines.||Ensure that each registered nurse has an annual competency.||PA Moderate||Reporting Complete||06/07/2017|
|Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.||Four of the ten medicines charts reviewed did not show evidence of the medicines having been reviewed within the previous three months. This requirement remains from the previous audit. Only one staff member signs for administration of controlled drugs when these are given. Some medicines are crushed however indications for this are not included in the prescription.||Ensure that review of medications occurs three monthly or as per frequency documented in the resident file. Ensure that the medication administration sheet is signed by two staff when controlled drugs are administered. Ensure that the general practitioner documents any requirement for crushing of medications.||PA Moderate||Reporting Complete||06/07/2017|
|The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.||Chemicals are not locked in a secure area when not in use.||Ensure that chemicals are kept in a secure area when not in use.||PA Moderate||Reporting Complete||06/07/2017|
|Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is undertaken by suitably qualified and/or experienced service providers who are competent to perform the function.||Not all residents have an InterRAI assessments completed to date.||Ensure that interRAI assessments are completed for each resident as scheduled.||PA Negligible||Reporting Complete||29/03/2018|
|The organisation has a quality and risk management system which is understood and implemented by service providers.||The previous quality plan has not been reviewed as per schedule. A current quality plan is not documented.||Review the 2015 to 2016 quality plan. Document, implement and review a quality plan for the current period.||PA Low||Reporting Complete||29/03/2018|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Data is not always analysed with review of trends leading to quality improvement.||Analyse data and review trends to improve service delivery with documentation of discussion at staff meetings.||PA Low||Reporting Complete||29/03/2018|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Registered nurses do not have a documented orientation programme indicating that they have completed an orientation relevant to their needs.||Ensure that any new registered nurse completes an orientation programme.||PA Low||Reporting Complete||29/03/2018|
|Consumers who have additional or modified nutritional requirements or special diets have these needs met.||Not all kitchen staff have completed food safety training.||Ensure that all kitchen staff have completed food safety training.||PA Low||Reporting Complete||29/03/2018|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||Corrective actions are not taken when fridge and freezer temperatures are identified as not being within normal range.||Ensure that all fridge and freezer temperatures remain within normal range.||PA Low||Reporting Complete||29/03/2018|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||Short term care plans are not always completed when needs arise for example wound management plans, urinary tract infections, skin tears. Documentation of individualised strategies to meet resident needs is not always completed.||i) Document short term care plans when needs arise. ii) Ensure that care plans include sufficient interventions or strategies to manage assessed need.||PA Moderate||Reporting Complete||29/03/2018|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||Individualised interventions are not always documented in activity plans. An activities programme is not documented for a sufficient length of time that would allow residents and family to plan ahead.||Document individualised activity plans for each resident with these reviewed in line with review of the care plans. Document an activity programme on at least a monthly basis.||PA Low||Reporting Complete||29/03/2018|
|Where progress is different from expected, the service responds by initiating changes to the service delivery plan.||The long-term care plan is not always updated as changes occur.||Ensure that the long-term care plan is updated as changes occur.||PA Moderate||Reporting Complete||29/03/2018|
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: 20 February 2017
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit; Verification Audit