Profile & contact details
|Premises name||Hillcrest Hospital|
|Address||86 Friesian Drive Mangere Auckland 2022|
|Service types||Physical, Rest home care, Medical, Dementia care, Geriatric|
|Certification/licence name||CHT Healthcare Trust - Hillcrest Hospital|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||22 November 2022|
|Certification period||48 months|
|Provider name||CHT Healthcare Trust|
|Street address||97 Great South Rd Market Road Auckland 1543|
|Post address||PO Box 74341 Market Road Auckland 1543|
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: 23 November 2020
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||(i). Three resident care plans in the dementia unit (two file reviews and one extra for clarification) included the need for behaviour interventions but did not include individualised and specific interventions. (ii). One hospital level care plan did not include the REAP program in the care plan. (iii). One hospital level resident did not have the recognition of pain in the care plan or mouth care interventions for a nil by mouth resident with known pain. (iv). One hospital level did not hav… (this text has been trimmed due to space limits).||(i). Ensure that care plan interventions are individualised and specific. (ii) – (iv) Ensure that care plans document the interventions to manage current care needs.||PA Moderate||Reporting Complete||05/05/2021|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||a) One younger person with a physical disability did not have the risk of aspiration and need to sit upright during feeds identified on the care plan. Staff stated there have been no incidents; and b) one resident (under LTS-CHC) commenced on insulin did not have the resident’s diabetic status/interventions identified on the care plan.||a) and b) Ensure interventions are documented for changes in health.||PA Low||Reporting Complete||20/02/2019|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||(i). One hospital level resident had a left-over meal stored on the shelf that had mould growing on it. (ii). The fridge in the dementia unit kitchen (that was freely accessible to residents) contained a combination of; expired food, food that had not been dated on opening and cream cheese with mould growing on it.||(i). Ensure that all food is safely stored according to the food control plan. (ii). Ensure that expired food is discarded, food is dated and monitored daily.||PA Moderate||Reporting Complete||16/03/2021|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i). One hospital level resident did not have bed rail covers in situ as per the care plan. (ii). Behaviour monitoring and monitoring of where abouts was not documented for two hospital residents as per the care plans. (iii). On both days of audit, the service did not have sufficient linen, as noted through empty linen cupboards, staff interviews and one resident in bed with no linen on the bed (a bare mattress and only blankets). The bed was also wet.||(i). Ensure that all care interventions are implemented including bed rail covers. (ii). Ensure all monitoring is documented according to the care plan. (iii). Ensure fresh bed linen is always available and residents do not sleep in wet beds with no linen.||PA Moderate||Reporting Complete||16/03/2021|
|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.||Spray paint cans and potting mix were stored on the ground and in an unlocked cupboard in the dementia garden.||Ensure that all hazardous substances are stored in a safe manner in the dementia unit.||PA Moderate||Reporting Complete||16/03/2021|
|All buildings, plant, and equipment comply with legislation.||(i). The table and seating in the dementia garden were dirty. (ii). The walkways in the dementia garden were not clear constituting a falls hazard.||(i). Ensure that outdoor furniture is clean so that it can be used at any time by residents in the dementia unit. (ii). Ensure that the external areas are safe for residents.||PA Moderate||Reporting Complete||16/03/2021|
|The service respects the physical, visual, auditory, and personal privacy of the consumer and their belongings at all times.||Residents did not always have privacy, dignity and respect as witnessed on the days of audit. The following was identified during the audit: (i). The bedroom doors in the dementia unit have a glass panel in each and residents can be viewed through this even when the door is shut. One resident chooses to cover his with a towel. (ii). Resident feeders at mealtimes are not always taken off in a timely manner and one resident in the dementia unit was sighted 30 minutes after they had finished the m… (this text has been trimmed due to space limits).||Ensure that residents are treated with dignity and respect with privacy when required around personal cares and time to self.||PA Moderate||Reporting Complete||19/04/2021|
|Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.||(i). One toilet in the hospital wing has no call bell, and one bed in the hospital wing had been moved so that the resident had not access to the calls bell. (ii). The maintenance room and the art room both had a mixture of chemicals stored on shelves with no process in place to separate incompatible flammable chemicals. Both the boiler room and the electrical switchboard room had flammable rubbish (paper and cloths covered in paint) on the floor. (iii). The boiler room (an internal room) was … (this text has been trimmed due to space limits).||(i). Ensure that all residents have access to call bells and /or can easily access assistance. (ii). Ensure that the risks of fire caused by hot rooms, flammable chemicals, smoking, and rubbish are fully addressed with areas where rubbish had collected being monitored at frequent intervals. (iii). Monitor the temperature of the boiler room and ensure that it is appropriately ventilated. (iv). Review the smoking cessation programme in the service for staff and ensure that staff smoke only in… (this text has been trimmed due to space limits).||PA Moderate||Reporting Complete||19/04/2021|
|The use of enablers shall be voluntary and the least restrictive option to meet the needs of the consumer with the intention of promoting or maintaining consumer independence and safety.||Residents are restrained from full access to outdoor gardens and paths.||Ensure that residents have access to outdoor gardens and paths without any restraint of use.||PA Moderate||Reporting Complete||19/04/2021|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Corrective action plans with evidence of resolution are not always documented when issues are raised e.g. through satisfaction surveys and meeting minutes.||Document corrective action plans with evidence of resolution are not always documented||PA Low||Reporting Complete||05/05/2021|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||Two of two resident files in the dementia unit, included an activity plan, but there were no interventions documented for all of the 24-hour period.||Ensure that residents in the dementia unit have a 24-hour activity plan.||PA Low||Reporting Complete||11/08/2021|
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: 23 November 2020
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit