Highlands Hospital

Profile & contact details

Premises details
Premises nameHighlands Hospital
Address 49 Aberfeldy Avenue Highland Park Auckland 2010
Total beds41
Service typesRest home care, Geriatric, Medical
Certification/licence details
Certification/licence nameMetlifecare Limited - Highlands Hospital
Current auditorThe DAA Group Limited
End date of current certificate/licence10 January 2019
Certification period36 months
Provider details
Provider nameMetlifecare Limited
Street addressLevel 4 20 Kent Street Newmarket Auckland 1023
Post addressPO Box 37463 Parnell Auckland 1151

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: 09 August 2017

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
errorPlease Enter a ValuePlease Enter a ValueCIReporting Cancelled
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Staff education is planned and recorded by the service. Staff are supported and encouraged to attend ongoing recognised aged care education. Compulsory education session attendance is monitored by management. Annual appraisals are used as a tool for staff to identify ongoing educational needs. In three of six staff files reviewed the annual appraisals were not up to date. This does not meet the DHB contractual requirements found in section D17.7f. Ensure all staff annual appraisals are up to date to meet DHB contractual requirements. PA LowReporting Complete13/07/2016
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.Incident and accident reporting does not always show what follow up actions are taken. Staff state they are doing this but no documented evidence could be found in one of two files reviewed for residents who had a head injury. One file had no corresponding incident or accident form that could be located for a fall shown in the resident’s progress notes. Ensure all adverse events are correctly reported and that the forms are completed to identify and include any shortfalls and meet best practice standards by managing all risk factors. PA LowReporting Complete13/07/2016
Entry criteria, assessment, and entry screening processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies.An information brochure is available but there is no evidence that this is given out to families or residents upon enquiry to service. Three residents and families reported on interview that no written information was given on enquiry. Ensure up to date and relevant information is available for all residents and families on enquiry. PA LowReporting Complete13/07/2016
The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.One lounge area, the wall behind the hand basin in the doctors’ clinic and one bathroom wall (north-west bathroom) is exposed to water. The means these areas cannot be adequately cleaned to ensure infection control standards are maintained. Ensure maintenance is undertaken to ensure all areas can be cleaned to maintain all infection control standards of cleaning. PA LowReporting Complete13/07/2016
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.The education calendar in place is not followed by the service. Limited staff education has occurred since April 2017. Provide evidence that organisational the education calendar is implemented by the service. PA LowIn Progress
The organisation has a quality and risk management system which is understood and implemented by service providers.Not all aspects of the quality and risk management system is implemented. Provide evidence that the organisational quality and risk management system is fully implemented by service providers. PA LowIn Progress
Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.Three of the five residents (and two of the five families) reported that the overall activities provided (apart from special celebrations), were not meaningful to the resident. Provide evidence that activities are consistently meaningful to the residents. 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.Five of the six residents’ files sampled did not consistently meet the organisational and contractual requirements for assessments, planning, evaluation and review of the residents. Provide evidence that the timeframes for assessment, planning, GP reviews and evaluation of care meet organisational and contractual requirements. PA ModerateReporting Complete22/11/2017
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.Four of the six files sampled did not have care plans that reflected the resident’s current needs. Provide evidence that the care plan interventions are consistent with the needs of the residents. PA ModerateReporting Complete22/11/2017
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.Corrective action planning is not consistently undertaken. Provide evidence that corrective action plans are put in place to address areas requiring improvement. PA ModerateReporting Complete20/12/2017
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.Not all incident forms identify if family have been notified and not all opportunities for service improvement are documented. Provide evidence that incident and accident forms are fully completed to meet policy requirements. PA LowReporting Complete20/12/2017

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. 

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 reports

Audit date: 09 August 2017

Audit type:Surveillance Audit

Audit date: 02 November 2015

Audit type:Certification Audit

Audit date: 06 May 2014

Audit type:Surveillance Audit

Audit date: 20 November 2012

Audit type:Certification Audit

Audit date: 19 May 2011

Audit type:Surveillance Audit

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