Carnarvon Private Hospital

Profile & contact details

Premises details
Premises nameCarnarvon Private Hospital
Address 20 Lincoln Road Henderson Auckland 0610
Total beds60
Service typesRest home care, Geriatric, Medical
Certification/licence details
Certification/licence nameCHT Healthcare Trust - Carnarvon Private Hospital
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence01 November 2023
Certification period36 months
Provider details
Provider nameCHT Healthcare Trust
Street address 97 Great South Rd Market Road Auckland 1543
Post addressPO Box 74341 Market Road Auckland 1543

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: 08 February 2022

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.(i). Four of seven wound care evaluations had not been completed as per the service policies and did not include all aspects of the wound evaluation. (ii). The pressure injuries did not have a formal assessment and wound care plan documented. (iii). Two rest home and one hospital level resident did not have the risks associated with warfarin use in the care plan. (iv). One hospital level resident’s care plan documented the risk of hypoglycaemia, but not how to recognise the issue. (v). One rest … (this text has been trimmed due to space limits).(i). Ensure that all wound care plans are evaluated according to policy. (ii). Ensure that all wounds have a documented assessment and wound care plan. (iii). Ensure that the risks associated with warfarin are documented in the care plan. (iv). Ensure that the signs and symptom of known risks such as hypoglycaemia are included in the care plan. (v). Ensure that monitoring is documented as per plan. (vi). Assess cultural needs for each resident and record interventions in the care plan with this … (this text has been trimmed due to space limits).PA LowReporting Complete23/11/2020
All buildings, plant, and equipment comply with legislation.Partial provisional: (i) A certificate for public use (CPU) has yet to be issued for stage 3 of the new build. (ii) The new wings are to yet to be completed with furnishings, shelving, cabinetry, paint, and floorings which are to be completed and installed as relevant to each space prior to occupancy. (iii) Hot water is not yet in place and therefore monitoring has not commenced. (iv) Locks and identification labels have not yet been installed in communal bathrooms. (v). Ensuite and comm… (this text has been trimmed due to space limits).(i) Ensure a copy of the code of compliance is completed and provided to the DHB and HealthCERT. (ii) Ensure that furnishings, shelving, paint, floorings, and handrails are installed to meet resident and staff needs. (iii) Ensure hot water checks are completed. (iv) Ensure communal bathrooms are identifiable and privacy is ensured. (v). Ensure that power, lighting, and water supplies are turned on and safety equipment such as disability rails installed PA LowReporting Complete23/11/2020
The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.Partial provisional: The building is not yet ready for occupancy. Equipment is yet to be installed. Ensure that the building is ready for occupancy. PA LowReporting Complete23/11/2020
Where required by legislation there is an approved evacuation plan.Partial Provisional: The fire evacuation plan Fire Service New Zealand for the new wing is not yet approved. Ensure that the fire evacuation plan includes the new wing and this is approved by the Fire Service. PA LowReporting Complete23/11/2020
An appropriate 'call system' is available to summon assistance when required.Partial Provisional: The call bell system is in place in the new wing but not yet operationalised. Operationalise the call bell system in the new wing. PA LowReporting Complete23/11/2020
The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code.Informal complaints are not documented as followed up through resident meetings and as the complaints are not logged there is no avenue to review any complaint trends. Ensure all complaints are documented and documented as followed up to the satisfaction of the complainant. PA LowReporting Complete04/07/2022
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.Outcomes of PRN medicines administered in nine out of 10 medication charts sampled were not consistently documented. Ensure administered PRN medicines are evaluated for effectiveness. PA ModerateReporting Complete04/07/2022

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: 08 February 2022

Audit type:Surveillance Audit

Audit date: 21 September 2020

Audit type:Certification Audit; Partial Provisional Audit

Audit date: 25 February 2020

Audit type:Partial Provisional Audit

Audit date: 26 March 2019

Audit type:Surveillance Audit

Audit date: 20 February 2019

Audit type:Partial Provisional Audit

Audit date: 23 August 2017

Audit type:Certification Audit; Partial Provisional Audit

Audit date: 08 September 2016

Audit type:Provisional Audit

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