Granger House Lifecare

Profile & contact details

Premises details
Premises name	Granger House Lifecare
Address	117 Shakespeare Street Greymouth 7805
Total beds	70
Service types	Medical, Rest home care, Geriatric

Certification/licence details
Certification/licence name	Heritage Lifecare Limited - Granger House Lifecare
Current auditor	The DAA Group Limited
End date of current certificate/licence	14 February 2025
Certification period	36 months

Provider details
Provider name	Heritage Lifecare Limited
Street address	16 Johnsonville Road Johnsonville Wellington 6037
Post address	PO 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: 06 June 2023

Outcome required	Found at audit	Action required	Risk rating	Action status	Date action reported complete
There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.	Overall, staffing levels remain challenging, with ongoing difficulties recruiting registered nurses in the region. Together with gaps between appointments of clinical services manager and a recruitment process underway for the care home manager, temporary arrangements are in place utilising an HLL roving care home manager. Further efforts are needed to successfully recruit and retain staff to ensure safe and sustainable staffing levels. Staffing levels and skill mix remains a risk for the servic… (this text has been trimmed due to space limits).	Continue to successfully implement recruitment efforts to ensure sustainable safe staffing levels and skill mix.	PA Low	Reporting Complete	27/09/2022
The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.	Work is underway to improve safety of the physical environment for residents as part of a major refurbishment in older parts of the facility. This will take some months to fully complete.	Complete the planned improvements designed to create a safe environment for residents.	PA Low	Reporting Complete	27/09/2022
Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care.	Not all quality data is being collected and analysed consistently in line with the requirements of the HLL quality and risk plan.	Provide evidence that all quality and risk management activities are conducted, completed, analysed, and managed to improve service delivery.	PA Low	In Progress
Fundamental to the development of a care or support plan shall be that: (a) Informed choice is an underpinning principle; (b) A suitably qualified, skilled, and experienced health care or support worker undertakes the development of the care or support plan; (c) Comprehensive assessment includes consideration of people’s lived experience; (d) Cultural needs, values, and beliefs are considered; (e) Cultural assessments are completed by culturally competent workers and are accessible in all settin… (this text has been trimmed due to space limits).	The residents’ care plans did not consistently include an interRAI assessment, and the support required to achieve the residents’ goals or aspirations were not clearly documented.	Provide evidence there is a comprehensive assessment in place and that the residents’ care plans describe the required support to achieve the residents’ goals.	PA Moderate	In Progress
Prior to a Māori individual and whānau entry, service providers shall: (a) Develop meaningful partnerships with Māori communities and organisations to benefit Māori individuals and whānau; (b) Work with Māori health practitioners, traditional Māori healers, and organisations to benefit Māori individuals and whānau.	Meaningful partnerships with Māori communities or organisations to benefit Māori individuals and whānau have not been developed.	Provide evidence that meaningful partnerships with Māori organisations have been developed to benefit Māori and whānau.	PA Low	In Progress
Service providers shall respond to tāngata whaikaha needs and enable their participation in te ao Māori.	Granger had no formal process in place to respond to the needs of tāngata whaikaha and enable their participation in te ao Māori.	Provide evidence that Granger has a process in place that enables a response to tāngata whaikaha needs and enables participation in te ao Māori.	PA Low	In Progress
Service providers shall follow the appropriate best practice tikanga guidelines in relation to consent.	Training on best practice tikanga guidelines around consent had not been provided.	Provide evidence that training on best practice tikanga guidelines in relation to consent has been provided.	PA Low	In Progress
Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services.	There are insufficient staff certified in first aid to cover the service 24/7.	Provide evidence that there is a certified first aid staff member on duty 24/7.	PA Moderate	Reporting Complete	06/11/2023
Service providers shall ensure there is a system to identify, plan, facilitate, and record ongoing learning and development for health care and support workers so that they can provide high-quality safe services.	The education programme at Granger has not been delivered to schedule and staff have not received education on the Code of Rights, cultural safety, Māori and Pasifika models of care, Te Tiriti o Waitangi, te reo Māori, tikanga guidelines, care for Pasifika and tāngata whaikaha, or equity.	Provide evidence that the education programme is being delivered to the schedule and that it includes education on the Code of Rights, cultural safety, Māori and Pasifika models of care, Te Tiriti o Waitangi, te reo Māori, tikanga guidelines, care for Pasifika and tāngata whaikaha, and equity.	PA Moderate	Reporting Complete	06/11/2023
The decision to approve restraint for a person receiving services shall be made: (a) As a last resort, after all other interventions or de-escalation strategies have been tried or implemented; (b) After adequate time has been given for cultural assessment; (c) Following assessment, planning, and preparation, which includes available resources able to be put in place; (d) By the most appropriate health professional; (e) When the environment is appropriate and safe.	Restraint has been applied without any interventions to assess the need for restraint. Cultural needs had not been considered as part of the restraint process.	Provide evidence that all residents using restraint have had a documented assessment for the need for restraint that includes an assessment of the restraint being used as a last resort, after all other interventions or de-escalation strategies have been tried, implemented, and failed, and that the assessment includes a cultural assessment.	PA Moderate	Reporting Complete	06/11/2023
Service providers shall conduct comprehensive reviews at least six-monthly of all restraint practices used by the service, including: (a) That a human rights-based approach underpins the review process; (b) The extent of restraint, the types of restraint being used, and any trends; (c) Mitigating and managing the risk to people and health care and support workers; (d) Progress towards eliminating restraint and development of alternatives to using restraint; (e) Adverse outcomes; (f) Compliance w… (this text has been trimmed due to space limits).	Comprehensive reviews of all restraint practices used by the service have not taken place at least six-monthly as required.	Provide evidence that comprehensive review of all restraint practices used by the service have taken place at least six-monthly.	PA Moderate	Reporting Complete	06/11/2023
Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided.	Not all staff are completing an orientation programme on entry to the service.	Provide evidence that all staff entering the service have completed an orientation programme specific to their role.	PA Moderate	Reporting Complete	06/11/2023
There shall be an executive leader who is responsible for ensuring the commitment to restraint minimisation and elimination is implemented and maintained.	The RC has not completed education/training around restraint and its use.	Provide evidence that the RC has completed education/training around restraint and its use.	PA Moderate	Reporting Complete	06/11/2023
The frequency and extent of monitoring of people during restraint shall be determined by a registered health professional and implemented according to this determination.	There was no documentation in place to guide staff around the frequency and extent of monitoring of individuals using restraint, by a registered health professional. The registered health professional who has the RC role has not completed education/training for the role. The frequency of monitoring was not evident in the clinical record.	Provide evidence that the RC has had the education/training to make appropriate decisions around the frequency and extent of monitoring of individual people during restraint, and that the monitoring is appropriately and consistently documented.	PA Moderate	Reporting Complete	06/11/2023
Service providers shall ensure their health care and support workers can deliver highquality health care for Māori.	Staff interviewed were unable to describe the cultural requirements for Māori residents in their care and have not been given the appropriate training to address this.	Ensure staff have been trained in, and understand, their responsibilities for the delivery of high-quality care for Māori. Training is based around Te Tiriti o Waitangi and what this means to their practice, te reo Māori, Te Whare Tapa Whā model of care, tikanga guidelines, and access to Māori health supports.	PA Moderate	Reporting Complete	06/11/2023
Monitoring restraint shall include people’s cultural, physical, psychological, and psychosocial needs, and shall address wairuatanga.	People using restraint did not have an assessment, and therefore monitoring, in place that addressed people’s cultural, physical, psychological, psychosocial needs, or wairuatanga.	Provide evidence that people using restraint have had an assessment and monitoring which addresses their cultural, physical, psychological, psychosocial needs, and where applicable their wairuatanga.	PA Moderate	Reporting Complete	06/11/2023
Each episode of restraint shall be documented on a restraint register and in people’s records in sufficient detail to provide an accurate rationale for use, intervention, duration, and outcome of the restraint, and shall include: (a) The type of restraint used; (b) Details of the reasons for initiating the restraint; (c) The decision-making process, including details of de-escalation techniques and alternative interventions that were attempted or considered prior to the use of restraint; (d) If … (this text has been trimmed due to space limits).	There was no restraint register in place and no documentation in the residents’ files that provided an auditable record of the restraint in use. There was no evidence that advocacy and support had been offered to the resident or their family/whānau.	Provide evidence that an accurate restraint register is in place and that there is documentation in the residents’ files to support restraint use that provides an auditable record of the restraint in use. Provide evidence that advocacy and support had been offered to the resident or their family/whānau.	PA Moderate	Reporting Complete	06/11/2023
Health care and support workers shall be trained in least restrictive practice, safe practice, the use of restraint, alternative cultural-specific interventions, and de-escalation techniques within a culture of continuous learning.	Fifteen staff had completed a competency on restraint use but there was no evidence that education on least restrictive practice, safe practice, the use of restraint, alternative cultural-specific interventions, and management of behaviours that challenge had been delivered and staff were not familiar with requirements.	Provide evidence that all care staff have completed the required competency on restraint and that education on providing the least restrictive practice, safe practice, the use of restraint, alternative cultural-specific interventions, and management of behaviours that challenge has been delivered.	PA Moderate	Reporting Complete	06/11/2023
Each episode of restraint shall be evaluated, and service providers shall consider: (a) Time intervals between the debrief process and evaluation processes shall be determined by the nature and risk of the restraint being used; (b) The type of restraint used; (c) Whether the person’s care or support plan, and advance directives or preferences, where in place, were followed; (d) The impact the restraint had on the person. This shall inform changes to the person’s care or support plan, resulting f… (this text has been trimmed due to space limits).	Residents using restraint have no evidence of restraint evaluation in their files.	Provide evidence that the service understands the requirements in evaluating the use of restraint, and that evaluation is implemented in the service.	PA Moderate	Reporting Complete	06/11/2023
My right to make a complaint shall be understood, respected, and upheld by my service provider.	Complaints are not being managed as per the requirements laid out in the organisation’s complaints policy and procedure. Not all complaints made to the organisation are being documented.	Provide evidence that there is a process in place to accurately document complaints and that complaints are fully addressed with the complainant.	PA Moderate	Reporting Complete	25/01/2024
In implementing care or support plans, service providers shall demonstrate: (a) Active involvement with the person receiving services and whānau; (b) That the provision of service is consistent with, and contributes to, meeting the person’s assessed needs, goals, and aspirations. Whānau require assessment for support needs as well. This supports whānau ora and pae ora, and builds resilience, self-management, and self-advocacy among the collective; (c) That the person receives services that remov… (this text has been trimmed due to space limits).	Six of eight care plans reviewed did not fully describe the care the resident required to meet their assessed needs.	Provide evidence that care plans describe the required support needed to address the resident’s assessed needs.	PA Moderate	Reporting Complete	25/01/2024
Planned review of a person’s care or support plan shall: (a) Be undertaken at defined intervals in collaboration with the person and whānau, together with wider service providers; (b) Include the use of a range of outcome measurements; (c) Record the degree of achievement against the person’s agreed goals and aspiration as well as whānau goals and aspirations; (d) Identify changes to the person’s care or support plan, which are agreed collaboratively through the ongoing re-assessment and review … (this text has been trimmed due to space limits).	No evidence was sighted of a planned review of the residents’ care plans being undertaken within the past six to eight months.	Provide evidence that a planned review of the residents’ care plans has been undertaken.	PA Moderate	Reporting Complete	25/01/2024

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: 06 June 2023

Audit type:Surveillance Audit

Audit date: 02 December 2021

Audit type:Certification Audit

Audit date: 13 October 2020

Audit type:Surveillance Audit

Audit date: 15 November 2018

Audit type:Certification Audit

Audit date: 27 October 2017

Audit type:Provisional Audit

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