Charles Upham Retirement Village
Profile & contact details
|Premises name||Charles Upham Retirement Village|
|Address||Charles Upham 56 Oxford Road Rangiora 7400|
|Service types||Geriatric, Medical, Dementia care, Rest home care|
|Certification/licence name||Charles Upham Retirment Village Limited - Charles Upham Retirement Village|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||09 November 2020|
|Certification period||36 months|
|Provider name||Charles Upham Retirement Village Limited|
|Street address||Charles Upham Retirement Village 6/92 Russley Road Russley Christchurch 8042|
|Post address||6/92 Russley Road Russley Christchurch 8042|
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: 12 March 2019
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.||(i)In the respite (rest home level) resident file sampled from the serviced apartments, the initial progress notes lacked detail about the resident and any potential risks. (ii)Two long-term rest home level residents in the serviced apartments had gaps of up to six weeks with no progress notes written, including following documented medical concerns.||Ensure all progress notes are completed in a timely manner and are reflective of resident condition including progression or decline.||PA Low||Reporting Complete||24/01/2018|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i)One hospital resident with a resolved unstageable pressure injury had no documentation that could be located for wound care between 19 June 2017 and 2 August 2017 (ii) Seven of nine incident forms from July 2017 where the investigation identified that an update to the care plan was required, did not have the care plan updated.||(i)Ensure there is documented evidence of wound care assessments, plans and evaluation for all wounds. (ii)Ensure care plans are updated when an incident investigation identifies this is required.||PA Low||Reporting Complete||24/01/2018|
|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.||(i)One rest home level resident did not have an initial interRAI assessment completed until five weeks after admission. The long-term care plan was not completed within three weeks of admission and there was no interRAI reassessment completed when the same resident had a significant change of needs despite a referral to NASC for reassessment. (ii) one rest home resident in the serviced apartment did not have an interRAI completed within 21 days.||Ensure all long-term care plans and interRAI assessments are completed within the required timeframes, and updated to reflect progression or decline on resident condition.||PA Low||Reporting Complete||20/02/2018|
|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.||Several entries in the rest home controlled drug register did not document the time of administration||Ensure the controlled drug register is fully documented as required.||PA Low||Reporting Complete||10/07/2019|
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: 12 March 2019
Audit type:Surveillance Audit
- Charles Upham Retirement Village - Mar 2019 (docx, 35.42 KB)
- Charles Upham Retirement Village - Mar 2019 (pdf, 141.6 KB)
Audit type:Certification Audit
- Charles Upham Retirement Village - Aug 2017 (docx, 47.23 KB)
- Charles Upham Retirement Village - Aug 2017 (pdf, 185.05 KB)
Audit type:Partial Provisional Audit
- Charles Upham Retirement Village - Nov 2016 (docx, 43.77 KB)
- Charles Upham Retirement Village - Nov 2016 (pdf, 151.67 KB)
Audit type:Partial Provisional Audit