Holmdene Rest Home
Profile & contact details
|Premises name||Holmdene Rest Home|
|Address||17 Elizabeth Street Balclutha 9230|
|Service types||Rest home care, Geriatric, Medical|
|Certification/licence name||Presbyterian Support Services Otago Incorporated - Holmdene Rest Home|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||19 February 2020|
|Certification period||48 months|
|Provider name||Presbyterian Support Otago Incorporated|
|Street address||407 Moray Street Dunedin 9016|
|Post address||PO Box 374 Dunedin 9016|
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: 12 February 2018
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.||Of the twelve medication charts reviewed, two had two different types of chart for the same resident. It was not clear as to the medications that were to be given at any given time.||Ensure there is consistent charting to aid clarity of medication charts||PA Low||Reporting Complete||23/05/2016|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||i) One hospital resident (tracer) with documented weight loss, did not have interventions for weight loss management documented in the care plan, and the GP notes did not document this either. Care workers were aware and ensured good nutrition at meal times and were monitoring this; ii) One hospital resident with a history of pressure injury, did not have care plan interventions in place prior to the development of a new and current pressure injury; iii) One hospital resident with high risk for… (this text has been trimmed due to space limits).||i-v) Ensure that resident lifestyle support plans include nursing interventions for identified risks||PA Low||Reporting Complete||14/06/2016|
|Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome.||i) Three residents with short term care plans did not have a documented evaluation of the care interventions or the effectiveness of the interventions. It was unclear as to the status of the acute episode; ii) The evaluation on wound care notes did not sufficiently evaluate the progress of the wound healing. There was documentation that the dressing had been undertaken, however, the description lacked evidence of progress.||i) Ensure that short term care plans are evaluated on the regular basis and document the effectiveness of the nursing interventions provided; ii) Ensure that wound care plans document a comprehensive evaluation of the wound and the effectiveness of the interventions provided on a regular basis.||PA Low||Reporting Complete||19/07/2016|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Two of four hospital files reviewed included shortfalls around interventions. (i) The long-term care plan for a resident with undernutrition had not been updated to reflect the dietitian’s recommendations. (ii) One hospital resident long-term care plan had not been updated following return from a public hospital admission with a significant change in health.||(i)-(ii) Ensure that interventions are updated to support all current needs.||PA Moderate||Reporting Complete||12/06/2018|
|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.||(i) Two ‘as required’ medications in use were found to have expired and eyedrops in use on the trolley had exceeded the use by timeframe. (ii) Standing orders had not been reviewed annually as per requirements.||(i)Ensure all ‘as required’ medications and opened eyedrops are within the expiry dates. (ii) Ensure all standing orders are reviewed by the GP annually.||PA Moderate||Reporting Complete||12/06/2018|
|The facilitation of safe self-administration of medicines by consumers where appropriate.||One resident who was self-medicating had not been reviewed three monthly as per policy.||Ensure the competency of residents who self-medicate is reviewed three monthly.||PA Low||Reporting Complete||12/06/2018|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Four of six files reviewed (all staff who had commenced employment between March and August 2017), did not have completed orientations in their personnel files.||Ensure all new staff complete orientation documentation within policy timeframes.||PA Low||Reporting Complete||17/07/2018|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||(i)Education sessions required by the DHB contract and PSO policy cannot be confirmed as occurring within the last two years for the following – Aging and sexuality, pain management, and medication. (ii) Three of six staff files did not evidence three-month appraisals had occurred||(i)Ensure education required to meet contractual obligations occur within designated timeframes. (ii) Ensure all new staff participate in an appraisal at three months as per policy.||PA Low||Reporting Complete||17/07/2018|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i)Three of the seven wound assessments reviewed did not evidence that wound assessments were fully documented. (ii)Seven wound management plans and evaluation were reviewed, documentation did not reflect that wound dressings were completed at the required frequency.||(i) Ensure wound assessment documentation is fully completed for all wounds. (ii) Ensure dressings occur as per the wound management plan.||PA Low||Reporting Complete||17/07/2018|
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: 12 February 2018
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit