Elmwood House and Hospital

Profile & contact details

Premises details
Premises nameElmwood House and Hospital
Address44 Nelson Crescent Napier South 4110
Total beds39
Service typesGeriatric, Dementia care, Medical
Certification/licence details
Certification/licence nameThe Napier District Masonic Trust - Elmwood House and Hospital
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence17 November 2022
Certification period48 months
Provider details
Provider nameThe Napier District Masonic Trust
Street address 15 Devonshire Place Taradale Napier 4112
Post addressPO Box 7288 Taradale Napier 4141

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 2020

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
New service providers receive an orientation/induction programme that covers the essential components of the service provided.Records of staff orientation and training are inconsistent. Training records do not specifically document orientation to the dementia wing. Records of orientation of bureau staff prior to commencement of the shift are not maintained. There is no documented process for orientating staff who move into a new role within the facility. Provide evidence of the Identified and documented orientation requirements for bureau staff, the dementia wing, and for staff moving into a new role. PA LowReporting Complete02/05/2019
The appointment of appropriate service providers to safely meet the needs of consumers.Four of five staff files sampled did not contain completed police vetting, reference checks or job descriptions. Ensure all required recruitment processes are completed and documented in staff files. PA LowReporting Complete23/02/2021
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.(i) There were two resident files of the five files sampled that did not have care plans developed within the required time frame. (ii) There were three resident files (of the five files sampled) where initial interRAI assessments had not been completed within the required time frames. (iii) Four residents were overdue for their interRAI reviews. (i) Ensure all long-term care plans are completed within the required time frames. (ii) Ensure all initial interRAI assessments are completed within the required time frames. (iii) Ensure all interRAI reviews are completed within the required time frames. PA LowReporting Complete23/02/2021
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.There is no documented evidence confirming quality data is shared with staff. Ensure quality data is routinely shared with all staff and this is documented. PA LowReporting Complete23/02/2021
An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.The complaints register does not include documented detail of verbal complaints received. Ensure both written and verbal complaints are documented in the complaints register. PA LowReporting Complete23/02/2021

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.

Back to top