Profile & contact details
|Premises name||CHT Bernadette|
|Address||25 Taupo Avenue Mount Maunganui 3116|
|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 2019|
|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: 09 October 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|The facilitation of safe self-administration of medicines by consumers where appropriate.||The one resident that self-administers medication (insulin) does not have a documented competency assessment around self-medication.||Ensure all residents that self-administer medications have a competency assessment completed.||PA Low||In Progress|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Thirty-four areas of non-compliance were identified for improvement through the 2017 internal audit monitoring process. Corrective action plans were developed for the thirty-four areas not compliant. Eleven out of the thirty-four corrective actions did not have documented evidence of being followed-up and/or signed off as completed.||Ensure that all corrective action plans resulting from internal audits had been completed and signed off.||PA Low||In Progress|
|The use of enablers shall be voluntary and the least restrictive option to meet the needs of the consumer with the intention of promoting or maintaining consumer independence and safety.||There is one resident with two enablers (one bed rail and one lap belt). For the bed rail enabler there was no documented assessment or consent completed. For the lap belt enabler that had been in place for six months, there was no documented assessment or consent completed until one month before the audit.||Ensure that there are documented assessments and consents completed for all enablers.||PA Low||In Progress|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i) A hospital level resident had an emergency restraint implemented. It was in place for one week but no assessment or care plan (short-term) was documented. (ii) Three residents, each with two wounds, had both wounds in the same assessment, plan and evaluations. (iii) Four of the five resident files sampled (one rest home and three hospital) did not have interventions documented in the care plan to address all identified needs. Examples include: depression, behaviour, use of a special pres… (this text has been trimmed due to space limits).||(i) Ensure that an appropriate assessment and plan of care to reduce the risks is completed for any resident using restraint. (ii) Ensure each wound has an individual assessment, management plan and evaluation. (iv) Ensure that care plans include interventions for all identified needs. (iv) Ensure that cares for short-term needs are documented in a care plan. (v) Ensure monitoring/interventions that are required occur and are documented.||PA Moderate||In Progress|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||There was no documented evidence that quality/health and safety/staff meetings included discussion around quality data trends analysis and what actions were required by staff.||Ensure that staff meeting minutes include discussion of quality data trends analysis and actions required, if any.||PA Low||In Progress|
|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.||(i) There were expired medications in the upstairs Matakana medication cupboard. (ii) There were three bottles of expired eye drops in use in the hospital. (iii) One open bottle of eye drops in the rest home had not been dated when opened. (iv) Weekly medication fridge temperatures in the hospital have been 0 degrees or below since 27 August 2017 with no corrective action taken. (v) One registered nurse interviewed described administering medications such as paracetamol or loperamide that… (this text has been trimmed due to space limits).||(i)and (ii) Ensure expired medications are appropriately disposed of. (iii) Ensure all eye drops are dated when they are opened. (iv) Ensure medication fridges are maintained at a safe temperature. (v) Ensure only medications that are prescribed are administered. (vi) Ensure a GP reviews all medications at least every three months. (vii) Ensure the efficacy of ‘as required’ medication is 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: 09 October 2017
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Provisional Audit