Glengarry Rest Home & Hospital

Profile & contact details

Premises details
Premises nameGlengarry Rest Home & Hospital
Address 21 Glengarry Place Wairoa 4108
Total beds41
Service typesGeriatric, Medical, Dementia care, Rest home care
Certification/licence details
Certification/licence nameHeritage Lifecare (BPA) Limited - Glengarry Rest Home & Hospital
Current auditorThe DAA Group Limited
End date of current certificate/licence03 April 2024
Certification period24 months
Provider details
Provider nameHeritage Lifecare (BPA) Limited
Street address16 Johnsonville Road Johnsonville Wellington 6037
Post addressPO Box 13223 Johnsonville Wellington 6440

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: 25 January 2022

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.Residents care plans do not always describe the required support the resident needs to meet the desired outcomes. Provide evidence that care plans describe fully the required support the resident needs to achieve the desired outcomes. PA ModerateReporting Complete11/07/2022
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.While staff can identify/verbalise corrective actions taken in response to incidents or audits, these are not consistently documented, or reviewed for effectiveness. Neurological monitoring is not occurring as required by policy following unwitnessed resident falls. Ensure where improvements are required, the required actions are documented, implemented, and monitored for effectiveness. Ensure neurological monitoring is consistently occurring as required by policy post unwitnessed resident falls. PA ModerateReporting Complete07/07/2022
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Records are not available to demonstrate that staff have completed abuse and neglect training or fire safety training in 2021/2022 to date, although a fire drill most occurred most recently in January 2021. Records are not available to demonstrate that two care staff that have been working in the secure dementia unit for over 18 months have complete an industry approved qualification in dementia care. Ensure all staff complete regular training on abuse and neglect and fire safety procedures and records of attendance are maintained. Ensure staff working in the secure dementia unit have completed an industry approved qualification in dementia care within 18 months of employment and records are retained to demonstrate this. PA ModerateReporting Complete11/07/2022
The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.As a result of the changes in personnel in management roles, the quarterly review of progress in achieving the goals/objectives as detailed in the Glengarry Lifecare business and strategic plan has not occurred since June 2021. Although there is regular verbal communication occurring, the formal monthly facility managers’ report has not been completed since July 2021. Ensure the required processes are implemented to monitor progress towards achieving goals. PA LowReporting Complete11/07/2022
The organisation is managed by a suitably qualified and/or experienced person with authority, accountability, and responsibility for the provision of services.There has been restructuring of roles and responsibilities at a national level and changes in personnel in key roles. Staff at Glengarry report the multiple changes in care home management team since 10 September 2021 have created uncertainty. The Heritage Lifecare relief clinical services manager (CSM) is reported to also be the care home manager since 17 December 2021. The CSM does not have a job description or employment agreement for this expanded role. This change was not reported to Healt… (this text has been trimmed due to space limits).Ensure the role and responsibilities of the manager(s) are clearly identified in position description and employment agreement documents. Ensure HealthCERT is informed of changes in the person undertaking applicable management roles in a timely manner. PA ModerateReporting Complete11/07/2022
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.Care planning is not consistently provided within the required timeframes to safely meet the residents’ needs Provide evidence that long term care plans are developed within 21 days of admission and reviewed at least six monthly or as a resident’s needs change. Ensure behavioural management plans are reviewed at least six monthly and reflect resident’s needs. Ensure all residents are assessed by the GP monthly, unless the GP verifies that they are stable and able to be reviewed three monthly. Ensure residents’ care is planned within timeframes that safely meets the needs of the resident. PA ModerateReporting Complete11/07/2022
There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.There is a significant RN shortage, with RNs being provided by DHB until 6 March 2022. Caregiver shifts are not always able to be covered including for unplanned staff absences. There has not been a weekend cleaner since mid-December 2021. The previous formula for calculating staffing requirements is no longer in use. The management team were unsure of how staffing hours are calculated although data is being regularly monitored and reported by dashboard KPI reports. All the applicable organisation’s documents that provide the framework for staffing and skill mix are available and ensure these requirements are implemented for all roles. Continue recruitment activities to fill vacant positions. PA ModerateReporting Complete11/07/2022
The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.The present service is not coordinated in a manner that promotes continuity of care to residents. Provide evidence systems are in place to ensure coordinated care that promotes continuity is provided to residents. PA ModerateReporting Complete11/07/2022
Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.Activities that are meaningful to residents are planned, however they are not verified as being provided. A care plan identifying residents’ individual diversional, motivational, and recreational needs over a 24 hour period, with consideration of the resident’s previous lifestyle patterns were not in use in the secure dementia unit. Ensure a care plan identifying residents’ individual diversional, motivational, and recreational needs over a 24 hour period, with consideration of the resident’s previous lifestyle patterns are in use for residents in the secure dementia unit. Provide evidence that activities in the rest home, hospital, the secure dementia unit and for those under 65 years, are planned and provided to maintain residents’ skills, strengths, and interests. PA ModerateReporting Complete11/07/2022
Key components of service delivery shall be explicitly linked to the quality management system.The various meetings utilised to communicate key quality and risk information to staff and obtain feedback from residents are not occurring regularly including health and safety, staff meetings and resident meetings. When staff meetings occur, they have not included all applicable topics and the minutes have not been made available for staff. Ensure staff meetings, health and safety meetings and resident meetings occur in a regular scheduled manner, and the minutes include all relevant components and are made available for staff and residents in a timely manner. Ensure the hazard register is reviewed regularly. PA ModerateReporting Complete11/07/2022

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.

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