Castlewood Nursing Home

Profile & contact details

Premises details
Premises nameCastlewood Nursing Home
Address 101 Tarbert Street Alexandra 9320
Total beds24
Service typesRest home care
Certification/licence details
Certification/licence nameCastlewood Nursing Home Limited - Castlewood Nursing Home
Current auditorCentral Region's Technical Advisory Services Limited
End date of current certificate/licence17 January 2021
Certification period36 months
Provider details
Provider nameCastlewood Nursing Home Limited
Street address 101 Tarbert Street Alexandra 9320
Post address

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: 23 January 2019

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.i) The type of meetings and the timeframes for having the meetings do not align with the meetings policy. ii) Corrective action plans resulting from meetings are not always documented and implemented. i) Ensure the type of meeting and frequency of meetings aligns with policy. ii) Ensure corrective actions plans resulting from meetings are documented and implemented. PA LowReporting Complete06/06/2019
The organisation is managed by a suitably qualified and/or experienced person with authority, accountability, and responsibility for the provision of services.The manager has not completed the required management training as per the aged residential care contract. Ensure the manager completes relevant education to meet the aged residential care contract. PA ModerateReporting Complete15/05/2018
The organisation has a quality and risk management system which is understood and implemented by service providers.The quality and risk management system is ad-hoc with no evidence of overarching monitoring or reporting at a management level of the organisation. Ensure a quality and risk management framework is implemented with management oversight appropriate for the size and nature of the aged care service. PA ModerateReporting Complete15/05/2018
Key components of service delivery shall be explicitly linked to the quality management system.There is no process to link key components of service delivery to the quality and risk framework. Ensure a process is documented and implemented to link the key components of service delivery to a quality and risk framework. PA ModerateReporting Complete15/05/2018
A process to measure achievement against the quality and risk management plan is implemented.There is no clear process documented to monitor and measure achievement against the quality and risk management system. Ensure a quality and risk management system is implemented with clear processes to measure quality against. PA ModerateReporting Complete15/05/2018
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.i) Areas requiring improvement are not always identified. ii) Corrective action plans are not always developed or closed out. Ensure a process is implemented to identify, document and close out corrective action plans. PA ModerateReporting Complete15/05/2018
Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include: (a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk; (b) A process that addresses/treats the risks associated with service provision is developed and im… (this text has been trimmed due to space limits).There is no evidence of an implemented process to identify, monitor and mitigate risk. Ensure a process to identify, manage and mitigate risk is documented and implemented.. PA ModerateReporting Complete15/05/2018
There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.There is no formal documented policy or process to reflect safe staffing management for the aged residential care contract or standard obligations with regard to: i) Skill mix ii) Acuity levels; iii) Escalation planning; iv) On call arrangements v) Leave cover for the diversional therapist. Ensure a process is documented to formalise safe staffing management that meets all requirements. PA ModerateReporting Complete15/05/2018
The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.The governance document does not have key performance measures, timeframes and who is responsible and is not reflective of the current management structure. Ensure the governance document is current and reflects a planned, coordinated approach to services provided, including key performance measures which are regularly reviewed. PA LowReporting Complete17/07/2018
The service develops and implements policies and procedures that are aligned with current good practice and service delivery, meet the requirements of legislation, and are reviewed at regular intervals as defined by policy.i) There is no formalised process in place to ensure that policies and procedures align with good practice, meet legislative requirements or are reviewed in a timely manner. ii) The abuse and /or neglect of resident’s policy does not describe the procedure should abuse and /or neglect be suspected or identified. ii) There is no interpreter policy available to guide staff. i) Ensure a process is implemented to review policies in a timely manner to assure their currency and alignment with good practice and legislation. ii) Document a procedure to effectively manage any incidence of abuse and /or neglect. iii) Document an interpreter policy which includes the process to access interpreters and maintain current information on interpreter services available. PA LowReporting Complete17/07/2018
There is a document control system to manage the policies and procedures. This system shall ensure documents are approved, up to date, available to service providers and managed to preclude the use of obsolete documents.There is no document control system in place to ensure version control of policies. Ensure a document control process is written and implemented. PA LowReporting Complete17/07/2018
Professional qualifications are validated, including evidence of registration and scope of practice for service providers.i) There was no evidence of current annual practising certificates or pharmacy licence verification for the contracted staff. ii) The manager does not have a current relevant position description. i) Ensure a record of all annual practising certificates for contracted staff are maintained on staff files. ii) Ensure current and relevant position descriptions are in place for all staff. PA LowReporting Complete17/07/2018
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.There was no evidence of the content of in-service training held. Ensure in-service training content meets service requirements and is provided by appropriately qualified staff. PA LowReporting Complete17/07/2018
The appointment of appropriate service providers to safely meet the needs of consumers.Performance reviews are not consistently completed for all staff. Ensure all staff have performance reviews completed annually. PA LowReporting Complete06/06/2019

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.

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