Cromwell House Hospital

Profile & contact details

Premises details
Premises nameCromwell House Hospital
Address 3 Warborough Avenue Epsom Auckland 1051
Total beds50
Service typesRest home care, Geriatric, Medical, Dementia care
Certification/licence details
Certification/licence nameMilton Adams Limited - Cromwell House Hospital
Current auditorHealth Audit (NZ) Limited
End date of current certificate/licence05 June 2020
Certification period36 months
Provider details
Provider nameMilton Adams Limited
Street address 3 Warborough Avenue Epsom Auckland 1051
Post addressPO Box 26018 Epsom Auckland 1344

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: 23 October 2018

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
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.Sixteen interRAI assessments were not reviewed and evaluated within the required time frame that safely meet the needs of the resident. Ensure interRAI assessments are evaluated and reviewed within the required time frames. PA LowReporting Complete06/12/2017
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.There is no evidence that staff performance is consistently reviewed annually as required by facility policy. Maintain the annual performance reviews up to date. PA LowReporting Complete25/02/2019
An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.Informal concerns expressed by residents or external agencies are addressed but not recorded in or managed through the complaints system. Define those concerns, both formal and informal, that are to be captured in the complaints system and ensure that all corrective and preventive actions taken are recorded for quality improvement purposes. PA LowReporting Complete23/04/2019
The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk.Corrective and preventive actions following adverse events are not consistently implemented or documented as required by documented policy. Consistently document, implement and verify preventive actions as require by the facility policy. PA LowReporting Complete23/04/2019
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.Not all files sampled had current InterRAI assessments. Ensure care plans are evaluated using current interRAI assessments. PA ModerateReporting Complete23/04/2019
The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.Residents are not always protected from risk of harm in the environment: Ensure that potentially harmful items and areas are secluded from access by residents. PA LowReporting Complete21/05/2019

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. 

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 reports

Audit date: 23 October 2018

Audit type:Surveillance Audit

Audit date: 30 March 2017

Audit type:Certification Audit

Audit date: 09 February 2016

Audit type:Surveillance Audit; Partial Provisional Audit

Audit date: 07 April 2014

Audit type:Certification Audit

Audit date: 15 January 2013

Audit type:Surveillance Audit

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