CHT Bernadette
Profile & contact details
| Premises name | CHT Bernadette |
|---|---|
| Address | 25 Taupo Avenue Mount Maunganui 3116 |
| Total beds | 92 |
| Service types | Medical, Rest home care, Geriatric |
| Certification/licence name | CHT Healthcare Trust - CHT Bernadette |
|---|---|
| Current auditor | Health and Disability Auditing New Zealand Limited |
| End date of current certificate/licence | 31 March 2025 |
| 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 |
| Website | www.cht.co.nz/index.php |
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: 27 July 2023
| Outcome required | Found at audit | Action required | Risk rating | Action status | Date action reported complete |
|---|---|---|---|---|---|
| A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented. | Corrective actions identified in staff, quality and resident meetings are not always addressed, followed up and signed off. | Ensure corrective actions or recommendations identified during meetings are reviewed as signed off when addressed. | PA Low | Reporting Complete | 10/01/2023 |
| An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken. | (i). One complaint related to food was logged on 6 December 2021 and escalated to the unit manager however, there was no investigation and follow up actions recorded. The complaint was unresolved. (ii). One complainant interviewed stated dissatisfaction with the laundry service related to damage of personal clothing. The complainant confirmed the complaint was resolved. The complaint was recorded with no evidence of an investigation or follow up action. | (i). Ensure complaints are dealt with and feedback provided in a timely manner (ii). Ensure investigations and follow up actions are recorded against recorded complaints | PA Low | Reporting Complete | 10/01/2023 |
| An appropriate 'call system' is available to summon assistance when required. | There are ongoing technical issues with the call bell system that has not been fully addressed | Ensure that identified issues are fully addressed. | PA Moderate | Reporting Complete | 10/01/2023 |
| 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). Cleaning staff were observed to use chemicals from non-labelled and mis-labelled containers. (ii). Chemicals were present in unlocked sluices. (iii). Three chemical bottles had labels that were illegible. | (i)-(iii). Ensure all chemicals are labelled correctly and stored safely in a manner not accessible to residents and visitors. | PA Moderate | Reporting Complete | 10/01/2023 |
| Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services. | The service does not have sufficient numbers of registered nurses to have an RN on duty at all times as per the ARC contract D17.4 a. i. | Ensure a registered nurse is on duty at all times to meet the requirements of the ARC contract D17.4 a. i. | PA Low | In Progress | |
| A medication management system shall be implemented appropriate to the scope of the service. | (i). Medication room temperature monitoring is not monitored for two of two medication rooms. (ii). Medication fridge temperature monitoring has not been consistently monitored weekly for two of two fridges where medications are stored. (iii). On the day of the audit, one of two fridges was malfunctioning with no measures were in place to ensure safe storage of medications that require refrigeration. (iv). There was no system for checking and documentation of stock medication (imprest) for quan… (this text has been trimmed due to space limits). | (i). – (v). Ensure medicine management systems and processes are in line with policy, standards, and legislative requirements. | PA Moderate | In Progress | |
| The frequency and extent of monitoring of people during restraint shall be determined by a registered health professional and implemented according to this determination. | Restraint monitoring documentation for three resident records reviewed is not occurring at the frequency expected by the policy, assessments, or care plans. | Ensure restraint monitoring and documentation is completed as per assessment, care plan and in line with policy. | PA Low | In Progress | |
| Fundamental to the development of a care or support plan shall be that: (a) Informed choice is an underpinning principle; (b) A suitably qualified, skilled, and experienced health care or support worker undertakes the development of the care or support plan; (c) Comprehensive assessment includes consideration of people’s lived experience; (d) Cultural needs, values, and beliefs are considered; (e) Cultural assessments are completed by culturally competent workers and are accessible in all settin… (this text has been trimmed due to space limits). | (i). There were no interventions documented for one hospital resident with infected toe and rash on abdomen. (ii). One hospital resident did not have detailed interventions in the management of percutaneous endoscopic gastrostomy (PEG), restraint and Methicillin-resistant Staphylococcus aureus (MRSA) infection to guide staff in safe management of the resident. (iii). One rest home resident did not have care plan updated following review by a dietitian (June 2023) with the interventions required… (this text has been trimmed due to space limits). | (i). Ensure interventions are documented to manage acute changes. (ii). – (iii). Ensure care plans have detailed interventions to provide guidance to staff on care management and are updated to reflect changes to resident needs and management plan. (iv). Ensure that wound care evaluations are completed. | PA Low | In Progress |
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: 27 July 2023Audit type:Surveillance Audit
Audit date: 20 January 2022Audit type:Certification Audit
Audit date: 19 November 2020Audit type:Surveillance Audit
Audit date: 13 November 2019Audit type:Partial Provisional Audit
Audit date: 16 January 2019Audit type:Certification Audit
Audit date: 09 October 2017Audit type:Surveillance Audit