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: 19 August 2019
|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.||The manager/RN or clinical manager/RN cover the night shift if a staff RN is unavailable. Each time this occurs, a section 31 report is completed. Six section 31 reports were completed in April, and six in June and ten in July. The facility manager was recently on leave for 10 days and the clinical manager was needed to work the night shift over this time leaving no management staff available during the daytime hours.||Ensure adequate staffing is available to cover both clinical and managerial duties.||PA Moderate||Reporting Complete||28/01/2020|
|Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.||The current menu Highview are using has not been reviewed by a dietitian since the service started making their own meals.||Ensure the menu is reviewed by a dietitian to ensure all nutritional guidelines are met.||PA Low||Reporting Complete||28/01/2020|
|Where an episode of restraint is ongoing the time intervals between evaluation processes should be determined by the nature and risk of the restraint being used and the needs of the consumers and/or family/whānau.||Evidence of three-monthly reviews were missing in both residents’ files of residents using bedrails as restraint.||Ensure restraint minimisation policy is followed to meet the frequency of three-monthly reviews for residents using restraint.||PA Low||Reporting Complete||28/01/2020|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||The complaints register for 2019 (year to date) failed to include all actions taken (eg, acknowledgement of the complaint, investigation of the complaint).||Ensure the complaints register includes not only the complaint and evidence it is resolved, but all dates and actions taken.||PA Low||Reporting Complete||18/02/2020|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Staff meeting minutes failed to reflect evidence of informing staff of the corrective actions that were developed resulting from internal audits.||Ensure staff are kept informed regarding corrective actions where opportunities for improvement are identified.||PA Low||Reporting Complete||18/02/2020|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||The manager stated that there is a minimum of one staff trained in first aid and CPR on every shift, but staff files were removed when the previous owners left, and the auditor was unable to verify this in writing. The manager stated that first aid/CPR training is scheduled for later in the year.||Ensure that there is documented evidence to indicate that there is one staff member available 24/7 with a current first aid/CPR certificate.||PA Low||Reporting Complete||18/02/2020|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||Three of six wound care evaluations do not demonstrate progression or deterioration of wounds.||Ensure all wound care evaluations demonstrate progression or deterioration of wounds.||PA Low||Reporting Complete||18/02/2020|
|An appropriate 'call system' is available to summon assistance when required.||One shared room with two single beds has only one call bell accessible, next to one of the two beds.||Ensure that a call system is available to both residents sharing a double room.||PA Low||Reporting Complete||18/02/2020|
|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.||Four of six long-term residents did not have interRAI assessments completed within 21 days of admission.||Ensure interRAI assessments are completed within 21 days of admission to the service.||PA Low||Reporting Complete||30/06/2020|
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: 19 August 2019
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