Deverton House Rest Home

Profile & contact details

Premises details
Premises nameDeverton House Rest Home
Address 634 East Coast Road Pinehill Auckland 0630
Total beds21
Service typesRest home care
Certification/licence details
Certification/licence nameY&P NZ Limited - Deverton House Rest Home
Current auditorThe DAA Group Limited
End date of current certificate/licence20 November 2019
Certification period36 months
Provider details
Provider nameY&P NZ Limited
Street address 167 Landscape Road, Mt Eden Auckland 1024
Post address167 Landscape Road Mount Eden Auckland 1024

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: 28 March 2018

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
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.Education on safe and effective alternatives to restraint and the use of enablers is not included in the orientation programme or ongoing education programme for staff (in 2015 and 2016 year to date). Ensure staff are provided with training on restraint minimisation and the use of enablers. PA LowReporting Complete31/05/2017
Service providers responsible for medicine management are competent to perform the function for each stage they manage.The registered nurse`s medicine competency was not completed by a registered health professional. Ensure the registered nurse is deemed competent for medicine management by another registered nurse or by the DHB gerontology nurse specialist who visits the facility on a regular basis. PA LowReporting Complete31/05/2017
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).While there is a process for identifying new hazards, the existing hazards and mitigation strategies as detailed in the hazard register have not been reviewed since January 2015. Implement a process to regularly review the organisation’s hazard register and the management of hazards. PA LowReporting Complete31/05/2017
The appointment of appropriate service providers to safely meet the needs of consumers.None of the five staff and manager files reviewed (of staff employed for more than 12 months) contained a performance appraisal completed in the preceding 12 months. There is currently no system in place to identify when staff are due their annual appraisal. Ensure the annual staff performance appraisal process is implemented and records are retained and maintained. PA LowIn 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).It was identified during audit that: The sluice room has key pad access but was open for the duration of the audit. Chemicals were present. The fire evacuation exit had obstacles (two portable clothes racks) partially obstructing the egress. The ramp progresses to an uneven cobbled pathway. The top of the handrail on the deck needs repair. This is rusty and has some sharp edges that may cause unintentional injury. The dining room floor had been mopped. The floor was visibly wet and the ‘hazard w… (this text has been trimmed due to space limits).Ensure all hazards/risks are reported and managed in a timely manner. PA ModerateIn Progress
Where progress is different from expected, the service responds by initiating changes to the service delivery plan.When progress is different from expected, the service does not evidence consistently that repeat falls risk assessments are completed, the long term care plans are updated to reflect the changes that have occurred or that a short term care plan has been developed until the issue has resolved. Ensure falls risk assessments are conducted following a fall, and a short term care plan is developed when a resident`s progress changes and that the long term care plan is updated as required. PA ModerateIn Progress
The organisation is managed by a suitably qualified and/or experienced person with authority, accountability, and responsibility for the provision of services.The facility manager does not have a job description in her personal file although notes being responsible for ensuring the day to day care needs of the residents are met. The registered nurse was notified to HealthCERT as being the Clinical Care Manager in December 2017. The current job description on file is for a registered nurse. Ensure the roles and responsibilities of the facility manager and clinical manager or registered nurse are clearly defined, and HealthCERT are notified of who is responsible for ensuring the day to day needs of residents are being met. PA LowIn 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.There is no evidence in a resident’s file to demonstrate the general practitioner was notified of an incident. The resident had a fall and sustained an injury to the head. Neurological observations had not been initiated and a post falls reassessment had not been completed. There is no clear process that demonstrates that incident related information (eg, falls) is being communicated and evaluated during residents’ routine GP reviews. There are multiple copies of resident assessments in the resi… (this text has been trimmed due to space limits).Residents’ records demonstrate that the general practitioner is informed of adverse events in a timely manner, and staff undertake appropriate interventions for reported events. Ensure reported events (eg, falls) are evaluated during GP routine reviews. A process is implemented to ensure only current / relevant documents are in the residents’ files. There is a consistent process in place to record communications with residents and families. Ensure the dates when vital signs and weights are obta… (this text has been trimmed due to space limits).PA ModerateIn Progress
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.Changes in interventions required are not updated in the care plans following the interRAI reassessment and care plan evaluations. Ensure the interventions required in individual resident’s care plans are updated to include changes resulting from the interRAI assessment and other assessments. PA ModerateIn Progress
Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.Individual resident’s activities plans are not well documented, or linked to the long term care plan, or goal focused. It was unable to be evidenced that the activities goals have been reviewed / evaluated or how this review occurs. A resident was observed to be leading an activity. A staff member was not overseeing the activity in progress. Staff facilitating the activities programme have not been provided with appropriate training. Ensure that activities are planned to meet residents’ assessed needs and goals, and that the programme is evaluated in a timely manner. Ensure activities are appropriately supervised and facilitated by an appropriately trained staff member. PA LowIn 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.A quantity of resident medicines and supplements for return to pharmacy was not stored securely. There is a number of residents’ eye medicines that are not appropriately stored / secured. Ensure all medicines are stored securely and appropriately and unwanted medicines are disposed of safely. PA ModerateIn Progress
There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.There are reported to be three staff on leave at the time of the audit. There are three to five days a week in the four weeks of rosters sighted where staff have been rostered to undertake two different shifts in the same day. The facility manager is working week days as the facility manager then working the weekends in the laundry and kitchen hand role each week. The clinical records audit that evaluates the contents of risk assessment, care plans and evaluations was undertaken by the facility … (this text has been trimmed due to space limits).Annual leave is planned to ensure safe staffing can be rostered and provided. Ensure clinical audits are undertaken by the registered nurse. PA ModerateIn 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. 

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: 28 March 2018

Audit type:Surveillance Audit

Audit date: 20 September 2016

Audit type:Certification Audit

Audit date: 30 July 2015

Audit type:Surveillance Audit

Audit date: 12 August 2013

Audit type:Certification Audit

Audit date: 30 April 2013

Audit type:Surveillance Audit

Audit date: 26 September 2012

Audit type:Provisional Audit

Back to top