The CARE Village
Profile & contact details
|Premises name||The CARE Village|
|Address||32 Taui Street Ngongotaha Rotorua 3010|
|Service types||Dementia care, Rest home care, Geriatric|
|Certification/licence name||Rotorua Continuing Care Trust - The CARE Village|
|Current auditor||Central Region's Technical Advisory Services Limited|
|End date of current certificate/licence||18 September 2018|
|Certification period||12 months|
|Provider name||Rotorua Continuing Care Trust|
|Street address||1092 Hinemaru Street Rotorua 3010|
|Post address||PO Box 1820 Rotorua 3040|
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: 03 August 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||i) Staffing, skill mix and roster methodology policies and procedures have not been developed for the new mixed service model for The CARE Village. ii) Clarity to be obtained about what constitutes a ‘hospital’ and what number of hospital level care residents are required to be in a house before it is considered a hospital, to inform staffing requirements in the mixed service contract (G17.4). iii) Not all staff members employed are familiar with what their roles will be at The CARE Village and … (this text has been trimmed due to space limits).||i) The service to develop staffing, skill mix and roster methodology policies and procedures. ii) Provide evidence of what constitutes the concept ‘hospital’, including what number of hospital level residents in a house are required before this house is considered a ‘hospital’. iii) Each staff member employed to be familiar with what their roles will be at The CARE Village and to have signed job descriptions.||PA Moderate||Reporting Complete||18/12/2017|
|The appointment of appropriate service providers to safely meet the needs of consumers.||There is no evidence that training in relation to the dementia unit standards have occurred for all staff.||Provide evidence of education and training relating to unit standards for dementia care for all staff.||PA Moderate||Reporting Complete||18/12/2017|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||i) The service does not currently have a planned orientation and induction programme specific to the new mixed services model. ii) Safety checks for volunteers have not been completed.||i) Provide evidence policies and procedures, systems and processes are developed to ensure induction and orientation of staff to new mixed services model for The CARE Village. ii) Safety checks/vetting needs to be completed on all new volunteers prior to them assisting in moving residents and their belongings to the new premises.||PA Moderate||Reporting Complete||18/12/2017|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||The service does not currently have a planned ongoing education and training programme for the new mixed services model of care.||Provide evidence of an ongoing education and training programme for the new mixed services model of care for The CARE Village.||PA Moderate||Reporting Complete||18/12/2017|
|The methods, frequency, and materials used for cleaning and laundry processes are monitored for effectiveness.||i) Policies and procedures, guidelines and schedules for cleaning and laundry processes have not been documented for The CARE Village. ii) Duties and tasks for cleaning and laundry have not been documented for the new mixed service model. iii) The service does not have processes in place to ensure chemical ratios and monitoring of water and dryer temperatures are appropriate for effective infection control in the new mixed service model of care. iv) Internal audits relating to cleaning and lau… (this text has been trimmed due to space limits).||i) Provide evidence that policies, procedures, guidelines and schedules for cleaning and laundry processes are documented and align with the new mixed services model of care at The CARE Village. ii) Duties and tasks for cleaning and laundry to be documented for the new model of care. iii) Document how chemical ratios and monitoring of water and dryer temperatures will be implemented and reviewed to ensure appropriate infection control in the new model of care. iv) Internal audit processes for cl… (this text has been trimmed due to space limits).||PA Moderate||Reporting Complete||18/12/2017|
|Service providers have access to designated areas for the safe and hygienic storage of cleaning/laundry equipment and chemicals.||i) Auditors could not verify that cleaning equipment is appropriate for the type and size of the service. ii) The planned storage of chemicals is not secure.||i) Provide evidence that cleaning equipment is appropriate for the type and size of the service, meeting infection control requirements. ii) Provide evidence that chemicals are stored safe and securely for all residents in a mixed service model of care.||PA Moderate||Reporting Complete||18/12/2017|
|Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.||Fire and emergency evacuation training and drills have not yet been completed.||Evidence of staff having received fire and emergency evacuation training.||PA Moderate||Reporting Complete||18/12/2017|
|Where required by legislation there is an approved evacuation plan.||There is currently no approved evacuation scheme for the service.||Provide evidence of an approved evacuation plan.||PA Moderate||Reporting Complete||18/12/2017|
|Alternative energy and utility sources are available in the event of the main supplies failing.||There is no emergency equipment, alternative energy source available and no emergency lighting.||Provide evidence of emergency equipment, alternative energy source and emergency lighting for emergency use.||PA Moderate||Reporting Complete||18/12/2017|
|Areas used by consumers and service providers are ventilated and heated appropriately.||There are no policies, processes or guidelines for the management of smokers, including signage and/or evidence that cessation programmes will be offered to smokers in the new mixed service model of care.||Provide evidence of policies, processes or guidelines for the management of smokers, including evidence that cessation programmes will be offered to smokers.||PA Low||Reporting Complete||18/12/2017|
|An appropriate 'call system' is available to summon assistance when required.||i) Policy, procedures and guidelines as well as the rationale for the use of motion detection sensors and pendant alarms are not in place. ii) The service does not currently have a documented process for identifying residents who may need the pendant alarms. iii) There is no documented process in place for residents who choose not to use pendant alarms to summon assistance. iv) There is currently no documented process for ensuring that those residents who need the pendant alarms and security wri… (this text has been trimmed due to space limits).||i) Provide evidence of policy, procedures and guidelines as well as the rationale for the use of motion detection sensors and pendant alarms. ii) Provide evidence of a process for identifying residents who may need pendant alarms. iii) Provide evidence of a process for residents who choose not to use pendant alarms to summon assistance. iv) Provide evidence of a process for ensuring that those residents who need the pendant alarms and security wrist-bands, will be wearing the alarms and wrist-ba… (this text has been trimmed due to space limits).||PA Moderate||Reporting Complete||18/12/2017|
|The use of enablers shall be voluntary and the least restrictive option to meet the needs of the consumer with the intention of promoting or maintaining consumer independence and safety.||The restraint minimisation and safe practice policy requires review.||Provide evidence the restraint minimisation and safe practice policy complies with this standard and is specific to the new mixed services model of care at The CARE Village.||PA Moderate||Reporting Complete||18/12/2017|
|The organisation identifies and implements appropriate security arrangements relevant to the consumer group and the setting.||i) There is no evidence of policy, procedures and guidelines, the rationale or consent processes for the use of security wristbands. ii) There is no documented policy on how the service intend to ensure residents wear the wristbands at all times.||i) Provide evidence of policy, procedures and guidelines as well as the rationale for the use of security wristband and consent processes. ii) Provide documented evidence of how the organisation intends to ensure residents wear the wristbands at all times.||PA Moderate||Reporting Complete||18/12/2017|
|All buildings, plant, and equipment comply with legislation.||The service does not have a CPU.||The provider to ensure all buildings, plant and equipment comply with legislative requirements.||PA Moderate||Reporting Complete||18/12/2017|
|Adequate space is provided to allow the consumer and service provider to move safely around their personal space/bed area. Consumers who use mobility aids shall be able to safely maneuvers with the assistance of their aid within their personal space/bed area.||Four rooms in two houses do not allow adequate space for a resident, staff and equipment to safely manoeuvre within their personal space.||Provide evidence that all personal spaces allow adequate and safe manoeuvrability of residents, staff and the residents’ equipment.||PA Low||Reporting Complete||18/12/2017|
|The responsibility for infection control is clearly defined and there are clear lines of accountability for infection control matters in the organisation leading to the governing body and/or senior management.||A policy for the responsibility for infection control, with clear lines of accountability for infection matters leading to the governing body is not defined.||Provide evidence of a policy for the responsibility for infection control with clear lines of accountability for infection matters leading to the governing body.||PA Low||Reporting Complete||18/12/2017|
|The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.||i) Equipment such as; raised toilet seats, mattress protectors, heel protectors, seat cushions, lifting aids or handrails in corridors were not available at the onsite audit (refer contract G15.3 a). ii) Equipment for general use, such as scissors, forceps, basic wound care, thermometers, sphygmomanometers, stethoscopes, weighing scales and blood glucose testing equipment could not be verified (refer contract G15.3 b-i to vi). iii) There were no guidelines for the provision of general equipment… (this text has been trimmed due to space limits).||i) Provide evidence equipment being available as required by the mixed service model contract. ii) Provide evidence that general equipment, as outlined in the contract, will be available to service providers. iii) Develop policies, procedures and guidelines for equipment use, storage and access. iv) Develop guidelines/processes for the provision of newspapers, personal mail, and facilitation of telephones for resident use. v) The service to provide evidence of how it will be providing a specifi… (this text has been trimmed due to space limits).||PA Moderate||Reporting Complete||18/12/2017|
|Protective equipment and clothing appropriate to the risks involved when handling waste or hazardous substances is provided and used by service providers.||Personal protective equipment was not evidenced during the onsite audit.||Personal protective equipment to be used when handling waste or hazardous substances.||PA Low||Reporting Complete||18/12/2017|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||i) Not all staff responsible for providing activities have completed the required education and training (refer contract G16.5 c-ii, e-ii; G17.1 e). ii) There is no recorded evidence of the appropriateness of the arrangements of the residents sharing a house with other residents and their and their families consent to this arrangement (refer contract G3.1 i; G4.1 a, c, d, e, f; G15.2A a, b, c, d). iii) Activities related policies and procedures for the new mixed service model have not been devel… (this text has been trimmed due to space limits).||i) Staff to be provided with training and education relating to activities specific to The CARE Village. ii) The process for residents’ allocation to lifestyle houses to be documented. ii) Provide evidence activities policies and procedures are developed.||PA Moderate||Reporting Complete||18/12/2017|
|Service providers follow a documented process for the safe and appropriate storage and disposal of waste, infectious or hazardous substances that complies with current legislation and territorial authority requirements.||i) The service does not have policies and procedures, specific to The CARE Village, to guide practice relating to the management of waste and hazardous substances, including processes for the collecting and storage of waste. ii) There is no sluice facilities or processes documented providing guidelines for practice in relation to the management of body fluids and human or infectious waste for the new mixed service model. iii) There is no provision of equipment or storage for equipment, such as u… (this text has been trimmed due to space limits).||i) Develop policies and procedures for the management of waste and hazardous substances, including the collection and storage of waste, specific to the new mixed services model of care at The CARE Village. ii) Develop processes and guidelines for the sluicing and management of body fluids, human and infectious waste for the new mixed service model. iii) The service to provide evidence of equipment, such as urinals, bedpans and wash bowls, as well as storage facilities for this equipment for the … (this text has been trimmed due to space limits).||PA Moderate||Reporting Complete||18/12/2017|
|The organisation has a clearly defined and documented infection control programme that is reviewed at least annually.||The infection control programme is not defined and there is no evidence of annual reviews of the programme being conducted.||Provide evidence the infection control programme is defined and annual reviews are conducted.||PA Low||Reporting Complete||18/12/2017|
|A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines.||There are no specific policies and procedures relating medicines management which align with the new mixed services model of care at The CARE Village.||Provide evidence of medicines management policies and procedures specific to the new mixed services model of care at The CARE Village.||PA Moderate||Reporting Complete||18/12/2017|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||i) The aspects of food preparation, storage, transportation, delivery and disposal could not be evidenced at The CARE Village for the new mixed service model. ii) There was no evidence of safety planning relating to free access to open plan kitchen layout for residents with dementia in the new model.||i) Provide evidence of policies, procedures and processes and their implementation for the food service to comply with current legislation and guidelines for the new mixed service model. ii) Provide evidence of minimisation of risk for residents with dementia relating to kitchen access in the new model.||PA Moderate||Reporting Complete||18/12/2017|
|The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.||i) There is limited evidence of documentation supporting the strategic direction of the organisation’s new mixed service model of care, including policies and procedures for risk management and a quality improvement plan specific to The CARE Village (refer contract G19.3 a to d and G19.4 a to d). ii) The risk management plan/register is not detailed (refer contract G19.3 a to d). iii) The business plan is not detailed (refer contract. iv) The change of trust board and change in the appointment o… (this text has been trimmed due to space limits).||i) Provide evidence of risk management policies, procedures and a quality improvement plan specific to The CARE Village. ii) Provide evidence that the risk management plan/register includes detail such as a description of risks, impact/consequences, level of risk, mitigation actions, who is responsible for the implementation of the changes (group or individuals) timeframes for implementation, review and sign off dates specific to The CARE Village. iii) The business plan to be specific regarding… (this text has been trimmed due to space limits).||PA Moderate||Reporting Complete||18/12/2017|
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: 03 August 2017
Audit type:Partial Provisional Audit
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit