Highview Home & Hospital
Profile & contact details
|Premises name||Highview Home & Hospital|
|Address||384 High Street Dunedin Central Dunedin 9016|
|Service types||Rest home care, Geriatric, Medical|
|Certification/licence name||Elsdon Enterprises Limited - Highview Home & Hospital|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||31 October 2022|
|Certification period||36 months|
|Provider name||Elsdon Enterprises Limited|
|Street address||1 Taaffes Glen Road Rangiora 7472|
|Post address||1 Taafes Glen Road RD 2 Rangiora 7472|
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: 22 February 2022
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.||(i) There are long tables in the upstairs dining room which would not allow much space for hospital residents and mobility equipment. Advised these are to be replaced by round tables, however, this has not yet happened.||Ensure there is sufficient space in the dining room for hospital residents and mobility equipment prior to occupancy of hospital level residents on the first floor.||PA Low||In Progress|
|The appointment of appropriate service providers to safely meet the needs of consumers.||(i) Evidence of reference checking was missing in all staff files reviewed, including casual staff (three permanent staff and eight casual staff); (ii) The service has not developed a transition plan to identify how many additional staff they would need to employ for the potential increase in number of hospital residents. They are currently stretched with staff and with the increase in hospital beds it was identified that more staff would need to be appointed.||(i) Ensure there is documented evidence to confirm that reference checking is documented as part of the employment process; (ii) Ensure that further staff are employed for the increase in hospital residents to safely cover the roster and leave.||PA Moderate||In Progress|
|Service providers have access to designated areas for the safe and hygienic storage of cleaning/laundry equipment and chemicals.||The current size of the laundry remains unsuitable for an increase in dirty linen. There are no specific handwashing basins in the laundry, but hand sanitiser is available. While there is identified dirty to clean flow in the small laundry, there is no specific area for the storage and folding of clean laundry. Clean laundry continues to be transferred into the resident dining/lounge area for folding.||Ensure the process around completing laundry on site is reviewed and an action plan implemented to ensure there is adequate hand hygiene available, clean areas for storage and folding of clean laundry and the laundry is suitable for an increase in dirty laundry.||PA Low||In Progress|
|Where required by legislation there is an approved evacuation plan.||The service is in the process of updating their fire evacuation procedure for review by the fire service.||Ensure the fire evacuation procedure is updated and approved by the fire service.||PA Low||In Progress|
|Adequate space is provided to allow the consumer and service provider to move safely around their personal space/bed area. Consumers who use mobility aids shall be able to safely maneuvers with the assistance of their aid within their personal space/bed area.||Reconfiguration and layout of rooms identified as possible hospital level rooms, remains an issue due to insufficient storage space for resident’s clothes and belongings, and insufficient room to manoeuvre bed, and equipment required for care staff and resident.||For the Rooms 202-207 and 209-211 on level one and rooms 109, 111, 112 on the ground floor to be approved as dual-purpose, the rooms would need to provide adequate storage space in these rooms as well as furniture and space for staff/resident and mobility equipment prior to it being approved as suitable for hospital level care. Following these changes, rooms would require approval as suitable by the DHB.||PA Low||In Progress|
|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.||There is no separate medication/treatment room and very little bench space and therefore the area is not ideal for managing medication for an increase in hospital/medical level residents.||Ensure there is appropriate space and storage for the safe management of medications for all hospital residents. Ensure this is in place prior to occupancy of further hospital residents.||PA Low||In Progress|
|Consumers have a right to full and frank information and open disclosure from service providers.||Ten of fifteen incident forms reviewed (December 2021 – January 2022) did not identify that family were informed following the incident.||Ensure incident forms identify that family are informed.||PA Moderate||Reporting Complete||17/05/2022|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Attendance at staff meetings is very low. There was no documented evidence that staff meeting minutes, which include quality data (e.g., complaints, adverse events, infection surveillance and internal audit results) have been shared with staff who were unable to attend the meetings. Interviews with staff confirmed that they have not been made aware of the documented quality results.||Ensure quality data is shared with staff.||PA Moderate||Reporting Complete||04/08/2022|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Evidence of casual staff completing an orientation was missing in all eight casual staff files reviewed.||Ensure all staff including casual staff complete an orientation and that this is documented.||PA Moderate||Reporting Complete||04/08/2022|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||An education and training plan for staff is not being fully implemented. Health and safety and fire safety are the only mandatory topics. Attendance was very low in 2021/2022 (YTD). The following topics were offered with numbers of staff attending (in parentheses); health and safety (24), fire safety (23), diabetes update (8), infection prevention and control (6), observing and responding to changes (5), chemical handling (10), personal cares (6), elder abuse (9) and continence management (10). … (this text has been trimmed due to space limits).||Ensure a training programme is implemented. Ensure all mandatory subjects are identified and reflect high levels of staff attendance.||PA Moderate||Reporting Complete||04/08/2022|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||Restraint monitoring and repositioning charts were not completed for two residents between early evening and when the night staff commence. Afternoon shift staff had not documented that bedrails had been monitored for safety and risk, and repositioning of the residents had not been documented for the whole time the residents were in bed||Ensure that monitoring and recording is completed for all residents when restraint is in place and for all residents who require repositioning and turning.||PA Moderate||Reporting Complete||04/08/2022|
|Service providers follow a documented process for the safe and appropriate storage and disposal of waste, infectious or hazardous substances that complies with current legislation and territorial authority requirements.||There is no sanitiser available in the facility as identified by an IC specialist.||For the expected increase of hospital level resident numbers and increase in commodes, the sanitiser identified as required as part of the long-term plan should be purchased.||PA Low||Reporting Complete||04/08/2022|
|An appropriate 'call system' is available to summon assistance when required.||There is no separate emergency call bell or sound. Two HCAs interviewed who work on the first level (AM and PM shifts) stated that when working (alone) on the first level, they are unable to contact downstairs staff to indicate there is an emergency unless they have their phone with them||Ensure a call bell system is available in all areas and a process around recognising emergencies is in place||PA Moderate||Reporting Complete||04/08/2022|
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.
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 reportsAudit date: 22 February 2022
Audit type:Surveillance Audit
- Highview Home & Hospital - Feb 2022 (docx, 42.05 KB)
- Highview Home & Hospital - Feb 2022 (pdf, 162.32 KB)
Audit type:Partial Provisional Audit; Surveillance Audit
- Highview Home & Hospital - Jul 2021 (docx, 60.71 KB)
- Highview Home & Hospital - Jul 2021 (pdf, 181.91 KB)
Audit type:Certification Audit
- Highview Home & Hospital - Aug 2019 (docx, 44.72 KB)
- Highview Home & Hospital - Aug 2019 (pdf, 172.47 KB)
Audit type:Provisional Audit