Fergusson Rest Home & Hospital
Profile & contact details
|Premises name||Fergusson Rest Home & Hospital|
|Address||654 Fergusson Drive Trentham Upper Hutt 5018|
|Service types||Rest home care, Geriatric, Medical, Dementia care|
|Certification/licence name||Bupa Care Services NZ Limited - Fergusson Rest Home & Hospital|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||11 May 2020|
|Certification period||36 months|
|Provider name||Bupa Care Services NZ Limited|
|Street address||Level 2 109 Carlton Grove Road Newmarket Auckland 1023|
|Post address||PO Box 113054 Newmarket Auckland 1149|
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 October 2018
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||i) Each of the units (hospital, rest home and dementia unit) had wound files and wound logs, however the logs did not match the current wounds being managed. ii) Two of the facility-acquired pressure injuries (both rest home) were not graded. iii) It was not clear in the wound documentation reviewed, which evaluation belonged to which wound. iv) Two hospital level wound plans had more than one wound documented per form. v) The service has a process where healed wounds continue to be monit… (this text has been trimmed due to space limits).||i) Ensure that the wound log is up to date. ii) Ensure that pressure injuries are graded. iii) Ensure that wound plans and evaluations are clearly labelled and linked to each other. iv) Ensure there is one wound per form. v) Ensure that the wound plan is clear regarding the treatment (monitoring and care interventions).||PA Moderate||Reporting Complete||18/06/2019|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||i) One hospital resident did not have the use of an enabler (bed rail) documented in the care plan; and ii) One rest home resident did not have a care plan documented for the management of complex partial seizures.||i-ii) Ensure care plans are documented for all assessed care needs.||PA Low||Reporting Complete||23/10/2018|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i) Three of eight rest home and two of nine hospital wound assessment and treatment plans did not evidence that the wounds had been reviewed in the prescribed timeframe; and (ii) In the rest home, one of eight initial wound assessments did not document the classification (stage) of pressure injury and two of eight wound assessments did not document the classification of skin tear as per Bupa Policy.||(i) Ensure wounds are reviewed within the prescribed timeframe; and (ii) Ensure the classification of wounds is documented on wound assessment forms as per Bupa Policy.||PA Low||Reporting Complete||23/10/2018|
|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) Medication was not evidenced to be administered as prescribed. A gap of six days was evident in one medication chart where the prescribed dose of anticoagulant was not evidenced to have been administered. (ii)Temperature recordings for the medication fridge in rest home were not evidenced to be recorded daily. (iii) A medication trolley was observed left unattended and unlocked in the rest home dining area.||(i) Ensure medication is documented as administered as prescribed. (ii) Ensure fridge temperature monitoring is conducted as per policy. (iii) Ensure medication trolleys are not left unlocked or unattended.||PA Moderate||Reporting Complete||23/10/2018|
|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) Temperature recordings for the medication fridge in hospital were not evidenced to be recorded daily. ii) Three eye drops were not dated on opening in the rest home and two eye drops were opened longer than the set time in the rest home. iii) The controlled medication book was not checked weekly in the rest home.||i) Ensure fridge temperature monitoring is conducted as per policy. ii) Ensure eye drops are dated on opening and are not stored longer than the set time once opened. iii) Ensure the controlled medication is checked weekly.||PA Moderate||Reporting Complete||18/04/2019|
|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 and two dementia care files reviewed did not have the initial interRAI and long-term care plan completed within required timeframes following admission. (ii) one hospital and one rest home file reviewed did not have six-monthly care plan evaluations completed within 6 months.||(i)-(ii) Ensure that interRAI’s, care plans and evaluations are documented within set timeframes.||PA Moderate||Reporting Complete||18/04/2019|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Two of three hospital level care and one of two rest home plans reviewed did not include all interventions needed. (i) one hospital file did not include interventions for care and prevention of pressure injuries. Also, the long-term care plan and a short-term care plan included interventions which were no longer applicable. (ii) one hospital file stated the resident was low falls risk, but the resident had sustained eight falls since January and two falls in September. (iii) The rest home le… (this text has been trimmed due to space limits).||(i)-(iv) Ensure care plans have clear interventions documented for all assessed care needs.||PA Moderate||Reporting Complete||18/04/2019|
|Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome.||i) One hospital and one dementia activity plan did not document evaluation of activities towards goals with ‘no change’ the only comment. Care plans for weight management for a rest home resident and the transfer plans for two hospital level residents had not been evaluated to document any progress towards goals. ii) Short-term care plans were not evaluated for one hospital and one rest home resident.||i) Ensure that care plans evaluate progress towards stated goals. ii) Ensure that the short-term care plans are evaluated or closed as needed.||PA Low||Reporting Complete||18/04/2019|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||In-service training hadn’t been completed for the following topics in the last two years; complaints/open disclosure, communication, end of life/death, challenging behaviour, nutrition/hydration, pain management, incontinence management, sexuality/intimacy and spirituality/counselling. Seven staff files were reviewed, three of the seven files did not have documented evidence of an up-to-date annual performance appraisal completed.||Ensure that sufficient staff attend education sessions to provide certainty that staff have received training in required areas. Ensure annual performance appraisals are up to date||PA Low||Reporting Complete||18/06/2019|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||There were 27 complaints documented in the quality meeting minutes from March to September 2017 (there were no quality meetings held in January, February, October, November and December 2017, so there were no complaint numbers available for those months). The manager could not locate a complaint register or documentation related to those complaints.||Ensure that there are copied of all complaints on the complaint register and documentation is maintained to reflect response letters and communication to the complainant.||PA Low||Reporting Complete||18/06/2019|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||i) Not all quality, staff and RN/clinical meetings have taken place according to the meeting schedule. There has been only one quality meeting, three RN/clinical meetings and three staff meetings in 2018 (scheduled as bi-monthly). In 201,7 there had been 7 of 12 quality, 4 of 12 staff meetings and 4 of 12 RN/clinical meetings completed in 2017 (these were all scheduled as monthly). Corrective actions identified in meeting minutes that required actioning have not been completed or signed off.… (this text has been trimmed due to space limits).||i) Ensure that facility meetings take place according to the meeting schedule and corrective actions required are completed and signed off. ii) Ensure that the internal audit schedule is adhered to and that all required corrective action plans are completed and signed off.||PA Low||Reporting Complete||18/06/2019|
The outcome required by the Health and Disability Services Standards.
Found at audit
The issue that was found when the rest home was audited.
The action necessary to fix the issue, as decided by the auditor.
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.
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.
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 reportsAudit date: 15 October 2018
Audit type:Surveillance Audit
- Fergusson Rest Home & Hospital - Oct 2018 (docx, 36.85 KB)
- Fergusson Rest Home & Hospital - Oct 2018 (pdf, 146.33 KB)
Audit type:Certification Audit
- Fergusson Rest Home & Hospital - Mar 2017 (docx, 45.82 KB)
- Fergusson Rest Home & Hospital - Mar 2017 (pdf, 179.21 KB)
Audit type:Surveillance Audit
- Fergusson Rest Home & Hospital - Mar 2015 (docx, 51.64 KB)
- Fergusson Rest Home & Hospital - Mar 2015 (pdf, 154.84 KB)
Audit type:Certification Audit