Eversleigh Hospital

Profile & contact details

Premises details
Premises nameEversleigh Hospital
Address 12 Coronation Street Belmont Auckland 0622
Total beds38
Service typesRest home care, Geriatric
Certification/licence details
Certification/licence nameGolden Concept E Limited - Eversleigh Hospital
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence01 May 2019
Certification period36 months
Provider details
Provider nameGolden Concept E Limited
Street address44 Montgomery Crescent Cockle bay Auckland 2014
Post address12 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: 13 December 2017

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
The organisation, through its infection control committee/infection control expert, determines the type of surveillance required and the frequency with which it is undertaken. This shall be appropriate to the size and complexity of the organisation. The IC coordinator collects infections based on swab results and pharmacy reports. The service IC definition process is not used. This means that only infections with a positive swab result or antibiotics are collected as part of infection surveillance data collected. Ensure that policy is followed, and all infections collected, collated and reported. PA LowIn Progress
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.i) Not all training has been delivered for 2017 and since the previous audit, examples include; chemical safety, abuse and neglect, residents’ rights, and cultural training. ii) Attendance has been less than 50 % for a selection of training, examples include; management of challenging behaviour, restraint, end of life, and emergency management. i) Ensure that the education schedule is fully implemented and education is provided to cover all contractual requirements. ii) Ensure that a process is put in place to ensure that all staff attend mandatory education and where attendance is low an education follow-up plan is implemented. PA ModerateIn Progress
In assessing whether restraint will be used, appropriate factors are taken into consideration by a suitably skilled service provider. This shall include but is not limited to: (a) Any risks related to the use of restraint; (b) Any underlying causes for the relevant behaviour or condition if known; (c) Existing advance directives the consumer may have made; (d) Whether the consumer has been restrained in the past and, if so, an evaluation of these episodes; (e) Any history of trauma or abuse, whi… (this text has been trimmed due to space limits).i) Three of four assessments did not document consideration of the risks associated with restraint. (ii) One (lap belt) did not have an assessment. (iii)) Four of four did not document consideration of alternatives prior to the use of restraint. Ensure that all residents with restraint have an assessment and assessments for restraint use identify and document the risks associated with the use of the restraint or enabler and document consideration of alternatives prior to the use of restraint. PA ModerateIn Progress
Each episode of restraint is documented in sufficient detail to provide an accurate account of the indication for use, intervention, duration, its outcome, and shall include but is not limited to: (a) Details of the reasons for initiating the restraint, including the desired outcome; (b) Details of alternative interventions (including de-escalation techniques where applicable) that were attempted or considered prior to the use of restraint; (c) Details of any advocacy/support offered, provided o… (this text has been trimmed due to space limits).(i)Two of four files did not include the use of restraint in the care plan. (ii) Three of four files did not have documented monitoring in place. Ensure that care plans document the care and monitoring required for safe use of restraint and that monitoring is documented according to time frames PA ModerateIn Progress
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.(i)Wound care: one hospital level resident had no wound plan in place; one hospital level resident had no reference to the wound in the long-term care plan (or short-term care plan). Six of eight wound assessments are not fully completed. (ii) Two of three hospital and one of two rest home did not have all required interventions documented in the long-term care plans including; one resident continence needs, the need to two carer assist, behaviour interventions and monitoring, air mattress sett… (this text has been trimmed due to space limits).(i)Ensure that wound management plans are documented for all identified wounds. Ensure that all wounds have a formal assessment and plan and that there are interventions documented in the short-term care plans or the long-term care plan updated to reflect the wound. (ii)Ensure that care plans document interventions for all resident assessed needs. PA ModerateIn Progress
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.Not all audits have been completed according to schedule. Examples include four audits for October and two for November. Ensure that all audits are undertaken as scheduled 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.(i)There was an expired vaccine (not normally stocked by the service) in the fridge and expired cream in the medication trolley. (ii) Non-packaged medication was signed as a group rather than individually, making it difficult to be sure what was given. (iii) Two charts had no photo ID. (iv) Oxygen was a prescribed intervention in the care plan, but not prescribed. It was not clear if the resident may had had it prescribed in the past. (i)Fully implement the checking process to ensure expired medications are not in stock. (ii) Ensure that non-packaged medications are signed for individually. (iii) Ensure medication charts have photo ID. (iv) Ensure that medication charts and care plans reflect current care. 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: 13 December 2017

Audit type:Surveillance Audit

Audit date: 22 February 2016

Audit type:Certification Audit

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