Eversleigh Hospital

Profile & contact details

Premises details
Premises nameEversleigh Hospital
Address 12A Coronation Street Belmont Auckland 0622
Total beds38
Service typesRest home care, Geriatric, Medical
Certification/licence details
Certification/licence nameBelmont Hospital Limited - Eversleigh Hospital
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence12 November 2022
Certification period12 months
Provider details
Provider nameBelmont Hospital Limited
Street address12A Coronation Street Belmont Auckland 0622
Post address12A Coronation Street Belmont Auckland 0622

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: 31 May 2021

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Consumers are provided with safe and accessible external areas that meet their needs.There was broken, uneven and slippery walking areas in one area posing a slip and/or trip hazard. Ensure all outdoor areas are safe and that walking paths are well maintained. PA ModerateIn 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.(i) One rest home, two hospital and residents did not have interRAI assessments and long-term care plans completed within 21 days of admission. (ii) One respite resident did not have admission assessments, or an initial care plan completed despite having been in the service for over three weeks. (i) Ensure an interRAI assessment and long-term care plan is completed within 21 days of admission. (ii) Ensure admission assessments and initial care plans are completed for all residents according to policy timescales. PA ModerateIn Progress
The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.The 2020 business plan has not been reviewed annually and a new business plan for 2021 is yet to be documented. Review the 2020 business plan and document a new business plan for 2021. PA LowReporting Complete30/11/2021
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.The monthly minutes are inaccurate and do not reflect discussion of data. Document accurate data and discussion related to data in the monthly meeting minutes and evidence use of data to improve services. PA ModerateReporting Complete30/11/2021
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.The Wi-Fi is not of a sufficient standard to allow safe and consistent operation of the electronic medication management system. Ensure there is sufficient infrastructure for the medication management system to operate safely. PA ModerateReporting Complete30/11/2021
The facilitation of safe self-administration of medicines by consumers where appropriate.(i). One respite resident did not have an assessment to self-medicate signed by the GP. (ii). The self-medicating residents did not have lockable medication storage. (i)-(ii). Ensure self-medication practices align with the policy. PA ModerateReporting Complete30/11/2021
Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.Resident attendance and participation in activities are not documented. Document all resident participation in planned activities. PA LowReporting Complete30/11/2021
All buildings, plant, and equipment comply with legislation.(i). There are broken vinyl floor seams in the kitchen (next to chiller) and missing vinyl flooring in front of the steriliser. (ii). The kitchen steriliser and hot water zip were out of order during the days of audit. (i)- (ii). Ensure all buildings and equipment comply with legislated standards. PA LowReporting Complete30/11/2021
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.A corrective action plan to address the issues raised in the November 2020 satisfaction survey has not been documented or changes in response to feedback made. Document and implement a corrective action plan to address the issues raised in the November 2020 satisfaction survey. PA ModerateReporting Complete06/12/2021
The service develops and implements policies and procedures that are aligned with current good practice and service delivery, meet the requirements of legislation, and are reviewed at regular intervals as defined by policy.Not all policies have been reviewed three yearly or in response to changes in legislation. Review policies at least three yearly or in response to changes in legislation. PA LowReporting Complete15/02/2022
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.Neurological observations were not consistently documented according to organisational policy for six of eight falls which required neurological observations. Ensure neurological observations are documented as per the organisation’s policy. PA LowReporting Complete15/02/2022

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.

Audit reports

Audit date: 31 May 2021

Audit type:Provisional Audit

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