Carnarvon Private Hospital
Profile & contact details
|Premises name||Carnarvon Private Hospital|
|Address||20 Lincoln Road Henderson Auckland 0610|
|Service types||Rest home care, Geriatric, Medical|
|Certification/licence name||CHT Healthcare Trust - Carnarvon Private Hospital|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||01 November 2020|
|Certification period||36 months|
|Provider name||CHT Healthcare Trust|
|Street address||97 Great South Rd Market Road Auckland 1543|
|Post address||PO 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: 20 February 2019
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.||An incident involving a police investigation was not notified to HealthCERT.||Ensure that all incidents are notified to HealthCERT where this is required.||PA Low||Reporting Complete||21/02/2018|
|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.||Three incidents where neuro observations were required did not have completed neuro observation forms available to confirm these had occurred.||Ensure neuro observations are completed and documented when a resident has a potential head injury.||PA Low||Reporting Complete||21/02/2018|
|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 were six imprest stock medications that had expired.||Ensure all medications in stock are checked for expiry dates.||PA Low||Reporting Complete||21/02/2018|
|The needs, outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning.||Risk assessments had not been completed on admission for two residents; 1) one respite care resident with a history of falls did not have a falls risk assessment and there were no falls prevention strategies documented and 2) there was no pain and pressure injury risk assessment completed for one resident admitted for palliative care.||Ensure applicable risk assessments are completed on admission.||PA Moderate||Reporting Complete||21/02/2018|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||a) The care plans for two long-term residents (one ARCC and one ACC resident) had not been updated to include interventions for weight loss. b) The short-term care plan for the respite resident had not been updated to include falls prevention strategies or the use and risks of using an enabler (cot sides). c) One long-term resident with a restraint did not have the associated risks of using a restraint documented in the care plan.||a) Ensure interventions are documented for residents with weight loss. b) Ensure the respite care plans are reviewed with each episode of respite care. c) Ensure risks are identified and documented for restraint and enabler use.||PA Low||Reporting Complete||21/02/2018|
|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).||The two resident files sampled that use restraint did not have documented comprehensive assessments.||Ensure assessments that meet the requirements of criterion 126.96.36.199 (a) to (h) are completed and documented.||PA Low||Reporting Complete||21/02/2018|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||There was not documented evidence that quality data has been analysed for trends.||Ensure that quality data is analysed for trends and that these are communicated to staff.||PA Low||Reporting Complete||21/08/2018|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||Education provided has not covered most required topics or providing support to all residents included younger people.||Ensure all staff receive training in all required areas including providing support to meet the needs of all residents.||PA Moderate||Reporting Complete||21/08/2018|
|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.||Four of four interRAI reassessments had not been completed six monthly as per policy||Ensure that interRAI assessments are completed at six monthly intervals as per policy||PA Low||In Progress|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Two of three records where restraint was used and one record where a resident used an enabler did not include documentation of risks related to the use of the equipment. The risk rating has been raised from a low risk documented at the previous audit to moderate.||Ensure that risks related to the use of an enabler or restraint are documented.||PA Moderate||In Progress|
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 2019
Audit type:Partial Provisional Audit
- Carnarvon Private Hospital - Feb 2019 (docx, 38.71 KB)
- Carnarvon Private Hospital - Feb 2019 (pdf, 130.79 KB)
Audit type:Certification Audit; Partial Provisional Audit
- Carnarvon Private Hospital - Aug 2017 (docx, 46.01 KB)
- Carnarvon Private Hospital - Aug 2017 (pdf, 179.92 KB)
Audit type:Provisional Audit