Concord House Rest Home
Profile & contact details
|Premises name||Concord House Rest Home|
|Address||42 Matai Road Greenlane Auckland 1051|
|Service types||Rest home care|
|Certification/licence name||Discover Oasis Limited - Concord House Rest Home|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||23 March 2020|
|Certification period||36 months|
|Provider name||Discover Oasis Limited|
|Street address||42 Matai Road Greenlane Auckland 1051|
|Post address||42 Matai Road Greenlane Auckland 1051|
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 November 2018
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|The service is able to demonstrate that written consent is obtained where required.||Two of five residents’ files reviewed did not have signed admission agreements on file for the current admission. One of the two residents had an agreement signed covering a previous respite admission.||Ensure each resident signs an admission agreement on the day the resident receives services or in the case of an emergency admission within 10 working days.||PA Low||Reporting Complete||03/07/2017|
|The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.||The facility manager was unclear regarding the situations that required the completion of a section 31 report. There were two instances where police were contacted to investigate a situation and a section 31 report had not been completed in either instance.||Ensure that all statutory and/or regulatory obligations in relation to essential notification reporting are adhered to.||PA Low||Reporting Complete||03/07/2017|
|The facilitation of safe self-administration of medicines by consumers where appropriate.||There is no formal identification documented by the GP on the medication orders for the two residents who are self-administering medicines, and there is no system in place to show that staff check with each resident that they have taken their medicines on each shift.||Ensure that the GP records on the medicine orders of each resident that the resident is self-administering all or part of their medicines, and ensure that there is a system in place to show that staff check that the residents have taken their medicines on each shift when due.||PA Low||Reporting Complete||03/07/2017|
|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.||1. One of three residents admitted since the previous audit did not have an initial assessment completed by the RN within 24 hours of admission. The other two residents were admitted many years ago and archived records were not reviewed. 2. The three residents who were admitted since the previous audit did not have an InterRAI completed within 21 days. However all three did have an InterRAI assessment. 3. The three residents admitted since the previous audit had not been assessed by a GP within… (this text has been trimmed due to space limits).||1. Ensure all newly admitted residents are assessed on admission by an RN. 2. Ensure all newly admitted residents have an InterRAI completed within 21 days of admission. 3 Ensure all newly admitted residents are assessed by a GP within 2 working days of admission.||PA Low||Reporting Complete||03/07/2017|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||One resident had a high risk clinical assessment identified during their InterRAI assessment, which was documented in their plan of care. However there was no corresponding intervention specified in the plan of care against the high risk assessment to guide staff on how to manage the resident’s high risk issue.||Ensure all plans describe the required support and interventions that staff need to follow when providing care.||PA Low||Reporting Complete||03/07/2017|
|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.||The manager was unaware of where the material safety datasheets were located for sighting on the day of the audit. The cleaner found them in the sluice room the following day after the audit had finished.||Ensure the location of the material safety datasheets are known to all staff.||PA Low||Reporting Complete||03/07/2017|
|The appointment of appropriate service providers to safely meet the needs of consumers.||The policy requires staff to undergo a formal interview, police vetting and reference checking. The interview and reference checking are not documented. Also missing was evidence of signed job descriptions.||Ensure each staff file includes evidence of an interview, reference checking and a signed job description.||PA Low||Reporting Complete||25/10/2017|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Staff files were missing evidence to indicate that they had completed a job-specific orientation programme.||Ensure that the content of the job-specific orientation programme is documented and signed by both parties when completed.||PA Low||Reporting Complete||25/10/2017|
|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 were two residents who due to their dementia, are unable to open the front and side (locked) gates and therefore cannot freely enter/exit the facility. Environmental restraint is covered in policy but the procedures around environmental restraint had not been implemented for either of these residents. Advised, that since the audit the locks have been removed.||Ensure environmental restraint procedures are implemented for any resident who is unable to freely leave the grounds of the facility.||PA Low||Reporting Complete||25/10/2017|
|The appointment of appropriate service providers to safely meet the needs of consumers.||The policy requires staff to undergo a formal interview, police vetting and reference checking. The reference checking was not documented for the new RN.||Ensure each staff file includes evidence of reference checking.||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.||(i)Two residents had an individual activity plan that had not been evaluated since 2016. (ii) Four of five resident files did not document an evaluation of care against stated goals.||Ensure that evaluations of care document progress towards stated goals at least six monthly.||PA Low||In Progress|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Two new staff files were missing evidence to indicate that they had completed an orientation programme.||Ensure that the content of the orientation programme is documented and signed by both parties when completed.||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).||(i) There is no documented hazard register for the service. (ii) Identified hazards are not discussed at staff meetings||(i) and (ii) Identify and assess all service risks and ensure a hazard register with mitigating strategies is documented and communicated to staff.||PA Moderate||In Progress|
|The organisation has a quality and risk management system which is understood and implemented by service providers.||The service was unable to locate an internal audit schedule, and no internal audits have been documented except a ‘pre-audit check’ (which achieved 100% compliance).||Ensure that an internal audit schedule is documented and implemented.||PA Moderate||In Progress|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||(i)One resident’s initial assessment and care plan was not fully completed. (ii) Two residents did not have all interventions documented to support assessed needs in their care plan; (a) for one resident ‘undernutrition’ identified as an interRAI CAP did not have interventions to support the risk in the care plan, and (b) one resident with documented uncooperative behaviour did not have this documented in the care plan.||Ensure all plans describe the required support and interventions that staff need to follow when providing care.||PA Moderate||In Progress|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||(i)There has been no group activity plan documented since April. (ii) Two residents had no documented individual activity plan. (iii) Two residents have a documented individual activity plan dated 2016.||Ensure that each resident has planned activities provided and documented that are meaningful and appropriate to resident needs.||PA Low||In Progress|
|Consumers have a right to full and frank information and open disclosure from service providers.||Five incident forms reviewed for October and November did not document if family had been informed following an incident.||Ensure that family are documented as informed following an incident and are part of the care planning process.||PA Low||Reporting Complete||25/03/2019|
|Key components of service delivery shall be explicitly linked to the quality management system.||Staff meetings are scheduled monthly, but these have not always been held monthly. There were no meetings for January, March, May, August, and October 2018.||Ensure that monthly staff meetings are documented as scheduled||PA Low||Reporting Complete||25/03/2019|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||The service has not documented training for staff since 2016. The requirement for staff to have eight hours of training annually could not be evidenced.||Ensure that staff training is documented to ensure that staff receive at least eight hours of training related to policies and procedures that comply with the ARRC agreement.||PA Moderate||Reporting Complete||25/03/2019|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||i) Not all food is labelled, dated and covered. (ii) Not all food labels are in English. (iii) Food temperatures are not documented; (iv) The Kitchen was not clean enough including drawers, kitchen surfaces, doors and cupboards.||(i) Ensure that all food is labelled covered and dated. (ii) Ensure that all food labels are in English (as well as Mandarin if needed). (iii) Ensure that food temperatures are recorded in accordance with the food control plan. (iv) Ensure that all aspects of the kitchen are clean.||PA Moderate||Reporting Complete||25/03/2019|
|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.||Two of three residents who were admitted since the previous audit did not have an interRAI and long-term care plan completed within 21 days. However, all three did have a current interRAI assessment and long-term care plan in place.||Ensure all newly admitted residents have an interRAI and long-term care plan completed within 21 days of admission.||PA Low||Reporting Complete||25/03/2019|
|The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.||(i) Bedrooms had chipped and peeling paintwork. (ii) Bedrooms had curtains that did not fit, did not match and were hanging down in places. (iii) The disability handle round one toilet had all the padding missing exposing the wood of the arm rest. (iv) Communal toilets had no privacy signs. (v) Water temperatures over 45 degrees were recorded in resident areas with no remedial actions documented.||(i) Ensure that the paintwork is repaired. (ii) Ensure that curtains fit the windows and hang from the curtain rails as designed. (iii) Ensure that the disability handles are repaired. (iv) Ensure all bathrooms can ensure privacy. (v) Ensure water temperatures are below 45 degrees in the resident areas.||PA Moderate||Reporting Complete||25/03/2019|
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 November 2018
Audit type:Surveillance Audit
- Concord House Rest Home - Nov 2018 (docx, 42.51 KB)
- Concord House Rest Home - Nov 2018 (pdf, 143.16 KB)
Audit type:Certification Audit
- Concord House Rest Home - Jan 2017 (docx, 42.88 KB)
- Concord House Rest Home - Jan 2017 (pdf, 165.54 KB)
Audit type:Provisional Audit