CHT Bernadette

Profile & contact details

Premises details
Premises nameCHT Bernadette
Address 25 Taupo Avenue Mount Maunganui 3116
Total beds92
Service typesMedical, Rest home care, Geriatric
Certification/licence details
Certification/licence nameCHT Healthcare Trust - CHT Bernadette
Current auditorBSI Group New Zealand Ltd
End date of current certificate/licence31 March 2025
Certification period36 months
Provider details
Provider nameCHT Healthcare Trust
Street address 97 Great South Rd Market Road Auckland 1543
Post addressPO Box 74341 Market Road Auckland 1543
Websitewww.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 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.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 LowReporting Complete10/01/2023
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 LowReporting Complete10/01/2023
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 ModerateReporting Complete10/01/2023
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 ModerateReporting Complete10/01/2023
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 LowIn 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 ModerateIn 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 LowIn 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 LowIn 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 2023

Audit type:Surveillance Audit

Audit date: 20 January 2022

Audit type:Certification Audit

Audit date: 19 November 2020

Audit type:Surveillance Audit

Audit date: 13 November 2019

Audit type:Partial Provisional Audit

Audit date: 16 January 2019

Audit type:Certification Audit

Audit date: 09 October 2017

Audit type:Surveillance Audit

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