Clutha Views Lifecare
Profile & contact details
|Premises name||Clutha Views Lifecare|
|Address||64 Essex Street Balclutha 9230|
|Service types||Rest home care, Geriatric, Medical, Dementia care|
|Certification/licence name||Heritage Lifecare Limited - Clutha Views Lifecare|
|Current auditor||The DAA Group Limited|
|End date of current certificate/licence||16 November 2023|
|Certification period||48 months|
|Provider name||Heritage Lifecare Limited|
|Street address||Level 2 111 Johnsonville Road Johnsonville Wellington 6037|
|Post address||PO Box 13223 Johnsonville Wellington 6440|
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 October 2021
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Service providers responsible for medicine management are competent to perform the function for each stage they manage.||Not all aspects of medication management meet requirements: - Pharmacy packs are not always being “checked” into the electronic medication system. - GP three monthly review dates do not accurately reflect the expected times frame on the electronic records. - Dates were not documented on one box of eye drops and one inhaler to show when they were opened. - An up-to-date medication competency was not evident in the file for the clinical services manager who is responsible for assessing staff me… (this text has been trimmed due to space limits).||All aspects of the medication management system reflect current legislation and accepted best practice guidelines.||PA Moderate||In Progress|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Corrective action processes are not consistently being applied with examples evident of issues of concern being identified and then not followed up as a corrective action, or a quality improvement. When corrective action plans are developed, there is a lack of evidence that all are being followed through to closure, or documentation is in a different place.||Corrective action plans are developed, implemented, and followed through to completion to ensure any shortfalls or areas requiring improvement are addressed to meet the specified standards or requirements.||PA Low||In Progress|
|Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome.||In the absence of comprehensive long term care plans, there was a lack of evidence that residents’ care was being consistently evaluated to measure achievement or response to planned interventions and outcomes.||Residents’ care plans are evaluated and reviewed at least every six months, or when clinically indicated by a change in their condition.||PA Moderate||In Progress|
|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).||Not all facility based actual or potential risks are being identified, monitored and evaluated at relevant intervals.||A facility based risk management plan/matrix that identifies all actual and potential risks, including those related to service provision, is developed and evaluated and reviewed at pre-determined intervals to assess the probability of change in the status of each risk.||PA Low||In Progress|
|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.||InterRAI assessments and Long-Term Care Plans are not being completed within 21 days of admission as required by the Aged Related Care Agreement (D16.2b) and nor was there any evidence of an interRAI assessment being used at six monthly intervals for review purposes.||All residents have a current interRAI assessment, and Long-Term Care Plans are completed within the required 21-day time frame.||PA Moderate||In Progress|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||There was insufficient evidence in the service delivery/care plans in four of the six files reviewed to ascertain the care requirements for these residents.||All residents’ service delivery/care plans are up to date and reflect the residents’ assessed needs and desired outcomes.||PA Moderate||In Progress|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||An inability to implement the documented rosters, non-replacement of staff with unplanned absences, outstanding key registered nurse duties, insufficient staff during key times of the day, staff expressing high stress levels from lack of staff and people taking on additional tasks, were examples of factors contributing to potential and significant risks for residents. The evidence available demonstrated that staffing levels are not always safe and appropriate, therefore timely, appropriate, and … (this text has been trimmed due to space limits).||Registered nurse roles and responsibilities, and the rostering of sufficient suitably qualified/skilled and/or experienced service providers, are fulfilled at the level required to ensure safe, timely and competent service delivery.||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: 27 October 2021
Audit type:Surveillance Audit
Audit type:Partial Provisional Audit; Certification Audit
Audit type:Certification Audit