Fergusson Rest Home & Hospital
Profile & contact details
|Premises name||Fergusson Rest Home & Hospital|
|Address||654 Fergusson Drive Trentham Upper Hutt 5018|
|Service types||Medical, Dementia care, Rest home care, Geriatric|
|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 2022|
|Certification period||24 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: 02 March 2020
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||The action plans resulting from internal audits have not all been followed up or signed off. This includes the internal audits for environmental nursing, environmental laundry, weight, moving and handling and clinical files.||Ensure that action plans following audits are followed up and signed off as completed.||PA Low||In Progress|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Four agency nurse induction forms picked at random did not have a completed orientation/induction form.||Ensure that all agency nurses have an orientation induction completed as per Bupa policy.||PA Moderate||In Progress|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||(i) Six of eleven staff files reviewed did not have an up-to-date annual appraisal documented. (ii) Five caregiver education records reviewed did not evidence eight hours training in the last year (iii) Not all education had been provided as per the Bupa schedule and attendance levels were low.||(i) Ensure that staff have a documented annual appraisal. (ii) Ensure that staff attend at least eight hours education annually. (iii) Ensure that all education is provided as per Bupa schedule.||PA Moderate||In Progress|
|Alternative energy and utility sources are available in the event of the main supplies failing.||The service does not have sufficient water stored to comply with the civil defence requirement of 20 litres per person per day for seven days||Ensure the water stored for emergencies complies with the civil defence requirement.||PA Low||In Progress|
|The facilitation of safe self-administration of medicines by consumers where appropriate.||Three of three rest home residents’ self-administering medications do not have current medication competencies in place.||Ensure all residents who self-administer medications have a competency assessment completed.||PA Moderate||In 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 dementia and two rest home residents did not have an initial interRAI assessment completed within 21 days of admission. ii) The interRAI re-assessment was not completed within six months for one rest home resident. iii) One hospital resident (YPD) did not have initial assessments, or long-term care plan developed or reviewed within timeframes as identified in policy.||Ensure all assessments, and care plans have been completed and reviewed within expected timeframes.||PA Low||In Progress|
|The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.||i) There were gaps of up to 18 days in progress notes documented by RNs on two dementia and two rest home files. ii) Two of four hospital files reviewed had a stamp only for a 24-hour review by the RN, however there was no written note/record.||Ensure progress notes reflect regular RN assessment.||PA Low||In Progress|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||i) There were no interventions documented in the long-term care plan or wound chart around the management of the wound dressing, signs and symptoms of infection including MRSA, and maintenance of skin integrity or dietary requirements for two hospital level residents with long-term chronic wounds. ii) There were no interventions or side effects of warfarin was documented in the care plan of a rest home resident with fragile skin prone to skin tears. iii) There were no cultural intervention… (this text has been trimmed due to space limits).||i) Ensure care plans document information around management of wound dressings during personal cares, signs and symptoms of infection and maintenance of skin integrity are included in care plan interventions. ii) Ensure the side effects of anticoagulants are documented to alert caregivers to increased risk of bleeding and bruising. iii) Ensure all residents identifying as Māori have their preferences documented in the care plan.||PA Moderate||In Progress|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||i) Two wound assessments had more than one wound documented on the plan in two rest and two hospital level residents. ii) The turning chart was not maintained as per care plan interventions for a hospital level resident with an unstageable pressure injury. iii) Restraint monitoring was not completed according to policy in three of three restraint files reviewed.||i) Ensure only one wound is documented on each wound chart. ii) Ensure the turning chart is completed as instructed in the care plan. iii) Ensure restraint monitoring is completed according to policy.||PA Moderate||In Progress|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||(i).Incidents and accidents are not consistently reported to meetings, including the quality and risk meeting for March, June and August 2019. (ii). The quality and risk meeting is also the resident minimisation meeting. The numbers of residents with restraint and enablers are reported, but there is no evidence of discussion around restraint minimisation or incidents associated with restraint (if any). (iii) The health and safety meeting is also the infection control meeting. Infection contro… (this text has been trimmed due to space limits).||(i). Ensure that incidents and accidents are reported to meetings. (ii). Ensure that restraint information is reported and the information reviewed with a view to reduce restraint and any issues from restraint discussed at the restraint meeting. (iii). Ensure that infection control statistics are reported at meetings and the trends and implications of these results discussed at the infection control meeting.||PA Low||In Progress|
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: 02 March 2020
Audit type:Certification Audit
- Fergusson Rest Home & Hospital - Mar 2020 (docx, 49.1 KB)
- Fergusson Rest Home & Hospital - Mar 2020 (pdf, 189.1 KB)
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