Fergusson House

Profile & contact details

Premises details
Premises nameFergusson House
Address 1 Carlton Street Glenholme Rotorua 3010
Total beds44
Service typesRest home care
Certification/licence details
Certification/licence nameFergusson House Restcare Limited - Fergusson House
Current auditorHealthShare Limited
End date of current certificate/licence19 April 2024
Certification period24 months
Provider details
Provider nameFergusson House Restcare Limited
Street address 678 Taikorea Road RD 3 Palmerston North 4473
Post address678 Taikorea Road RD 3 Palmerston North 4473

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: 15 February 2022

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
The methods, frequency, and materials used for cleaning and laundry processes are monitored for effectiveness.The hours currently allocated for cleaning may not be able to meet the additional demand for cleaning in the previous ORA apartment Review the impact of additional cleaning areas with staff and ensure there are adequate hours for cleaning allocated before the two residents return to the apartment. PA LowIn Progress
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.There was no documented evidence that actions taken to remedy areas requiring improvement had been implemented to good effect. Provide evidence that corrective actions are planned and agreed, implemented and then checked to ensure they have fixed the problem. PA LowIn Progress
The service is able to demonstrate that written consent is obtained where required.There was no evidence that signed consents had been obtained for all procedures. Provide evidence of signed consents. PA ModerateIn Progress
Where required by legislation there is an approved evacuation plan.It is not known if the approved evacuation scheme includes the ORA apartment located at the end of A wing. Trial fire evacuations that include the ORA apartment and its occupants have not yet occurred. Review the current evacuation scheme with Fire and Emergency Services New Zealand. Test the effectiveness of the emergency alert system in the apartment before residents move in. Ensure the residents have been part of a trial emergency evacuation. PA ModerateIn Progress
An appropriate 'call system' is available to summon assistance when required.There is currently no call bell system in the ORA apartment. Install a call system into the apartment. Ensure this is functional and integrated with the current rest home call system. PA LowIn Progress
The organisation identifies and implements appropriate security arrangements relevant to the consumer group and the setting.The location and ease of access to the apartment has potential security threats for rest home residents. Review the current security arrangements for A wing and ensure that rest home residents living in the apartment are kept safe. PA LowIn Progress
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.There are no consent for use of bed levers signed by residents. Ensure that residents who use bed levers have been assessed as competent and that placement of these is safe. Obtain the residents signed consent for their use. PA LowIn Progress
During a temporary absence a suitably qualified and/or experienced person performs the manager's role.The interim nurse manager does not have the skills and experience required to manage an aged care facility. Increase support for the interim nurse manager and/or implement solutions to ensure day to day services are safe, effective and efficient. PA ModerateIn Progress
The organisation has a quality and risk management system which is understood and implemented by service providers.The new quality and risk management systems have not been fully implemented. Staff are following previous systems. Information and outcomes from quality and risk monitoring was not shared at the last staff meeting. The new quality and risk management systems have not been clearly communicated and shared with staff. Ensure that the company’s quality and risk management systems are implemented, fully understood and followed by staff. PA LowIn Progress
All buildings, plant, and equipment comply with legislation.Not all systems could be tested as the electrical supply was shut off and there was no furniture. There are cooking appliances in place. Electrical systems, internal and external access and the apartment will need to be inspected when furniture is in place to confirm a safe environment. The existing systems for repairs and maintenance need to be explained to residents. Disconnect the oven. Ensure the electrical systems and all areas in the apartment (including layout of furniture) are safe for people requiring rest home level care. Ensure the intending residents understand the system for requesting repairs and maintenance. PA LowIn Progress
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.The policy and procedure set is incomplete and does not meet the requirements of these standards, current legislation and the ARC agreement. Clinical policies and the procedures lack detail and content about timeliness of processes and do not reflect current good practice. Staff have not been educated or informed about the policies or procedures. Review, update and implement the current policies and procedures to meet the requirements. Ensure all staff are educated about the policies and how to access these. PA LowIn Progress
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.An event between residents was not recognised as an incident that required reporting. Ensure all staff understand the full extent of incident reporting and their responsibility to communicate up all unwanted events. 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.Assessments, planning, provision and review of care is not always provided within timeframes to safely meet the needs of the resident. Best known practice for prevention and alleviation of pressure injuries, such as use of an air pressure mattress had not occurred. Ensure assessments, planning, provision and review of care is provided within timeframes that safely meets the needs of the consumer. Ensure all possible care interventions for prevention and alleviation of pressure injuries are provided. PA ModerateIn Progress
The infection control team/personnel and/or committee shall comprise, or have access to, persons with the range of skills, expertise, and resources necessary to achieve the requirements of this Standard.There is not a person on staff with the expertise or range of skills required to implement the infection control programme. Ensure there is a person on staff with the expertise or range of skills required to implement the infection control programme. 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.Systems for managing planned and/or unplanned staff absences are not established or effective. The formulas used to determining safe staffing levels do not take current residents’ acuity and needs into account. Staff who were not trained or assessed as competent have been assisting with resident feeding. There are insufficient numbers of staff maintaining first aid certificates, to cover all duties. Implement an effective system for replacing unexpected staff shortages. Review the current number of hours allocated to care staff and housekeeping to ensure these are sufficient to meet current resident’s needs. Ensure that only staff who are trained and assessed as competent, carry out resident cares. Ensure there is at least one staff member with a current first aid certificate on site 24 hours a day seven days a week (24/7) PA ModerateIn 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.The weekly stocktakes and the six-monthly quantity stock take of controlled medications were not consistently recorded as per legislative requirements. Temperatures in the medication room were higher than desired in storage areas. Ensure the weekly stocktakes and the six-monthly quantity stock take of controlled medications is consistently recorded as per legislative requirements. Ensure all medications are stored at below 25 degrees Celsius. 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. 

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: 15 February 2022

Audit type:Certification Audit; Partial Provisional Audit

Audit date: 10 March 2021

Audit type:Provisional Audit

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