Homestead Ilam Home and Hospital

Profile & contact details

Premises details
Premises nameHomestead Ilam Home and Hospital
Address 7 Ilam Road Upper Riccarton Christchurch 8041
Total beds40
Service typesGeriatric, Rest home care, Medical
Certification/licence details
Certification/licence nameKomal Holdings Limited - Homestead Ilam Home and Hospital
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence07 April 2021
Certification period36 months
Provider details
Provider nameKomal Holdings Limited
Street address 134 Rangiora Woodend Road Woodend 7610
Post addressPO Box 8309 Riccarton Christchurch 8440

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: 08 July 2019

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate 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.Discussion with both senior care staff and caregivers evidenced that staff are concerned regarding staffing levels; particularly at the weekends. A review of the staffing roster and staff on duty over four consecutive weekends evidenced that; over four weekends (16-day shifts) four shifts were a caregiver short. It was also noted that for the last two weeks one staff member had worked six shifts then five the next week (with no break in-between) one staff member had undertaken double shifts fo… (this text has been trimmed due to space limits).Review the staffing and ensure there are enough staff to fully staff the roster and adjust the roster depending on the needs of residents. PA ModerateReporting Complete22/05/2018
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.(i)Not all compulsory education has been provided, examples include privacy and sexuality and also challenging behaviour. (ii) Attendance at training has been low with less than 50% attendance numbers at 25% of training session viewed. (i)Ensure that all compulsory subjects are included in the training plan. (ii) Ensure that staff are provided with the information needed to ensure best practice. PA LowReporting Complete13/06/2018
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.Four of six care plans (three rest home and one hospital) had been updated, but obsolete interventions had not always been crossed and signed out as resolved or not current. Ensure that care plans contain up-to-date information and obsolete interventions are crossed out. PA ModerateReporting Complete13/06/2018
New service providers receive an orientation/induction programme that covers the essential components of the service provided.Of the seven staff files reviewed; two staff had no documented orientation (one RN and one DT) and two staff did not have an orientation completed in a timely manner, one RN was employed November and one caregiver employed October 2017, both had incomplete orientation documentation. Ensure that all staff have a documented orientation when they join the service and that orientations are completed. PA LowReporting Complete16/04/2019
The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.The dining area walls and ceiling and pole supporting beam in the dining room remain in situ and repairs are still needed. Ensure the dining room plan for repair/refurbishment is implemented. PA LowReporting Complete16/04/2019
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.Not all interRAI assessments and care plans were completed in required timeframes. (i) Initial interRAI assessments were not completed within 21 days of admission for one rest home resident. (ii) Initial long-term care plans were not completed within 21 days of admission for three (two hospital and one rest home) files reviewed. (iii) Follow-up interRAI assessments were not completed at least six monthly for one hospital resident. (i)-(iii) Ensure all interRAI assessments, care plans and evaluations are completed within contractual timeframes. PA LowIn Progress
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Three of six staff files reviewed did not have an appraisal completed in the last 18 months Ensure all staff have annual performance appraisals as per policy. PA LowIn Progress
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.(i) Two hourly position changes were not evidenced as implemented for one hospital resident. (ii) Two hourly monitoring charts at night and intentional rounding day checks were not documented for one rest home resident as per care plan instructions. (iii) Routine monthly observations and weight were not documented for May or June for a hospital resident. (i)-(iii) Ensure monitoring is implemented according to documented care plan interventions. PA LowIn Progress
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.Three of six care plans (one rest home and two hospital) had been updated; however obsolete interventions had not always been crossed and signed out as resolved or not current. Ensure that care plans contain up-to-date information and obsolete interventions are crossed out. PA ModerateReporting Complete30/10/2019
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 eyedrops and one nasal spray in current use were not dated on opening. (ii) Five recent entries in the controlled medication chart did not evidence the time of administration. (iii)There are a number of gaps evident in the signing chart (i). Ensure all eyedrop and nasal sprays are dated on opening and discarded as per manufacturer’s instructions. (ii). Ensure all entries in the controlled drug register include the time of administration. (iii). Ensure all medication is signed when PA ModerateReporting Complete30/10/2019
There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.Discussion with both senior care staff and caregivers evidenced that staff continue to be concerned regarding staffing levels; particularly at the weekends. The clinical nurse manager has covered on the floor on several occasions recently (including two-night shifts in the last two weeks) and is working long hours to manage her own role. A review of the staffing roster and staff on duty over two consecutive weeks evidenced that; the diversional therapist was not replaced for five days; eleven … (this text has been trimmed due to space limits).Review the staffing and ensure there are enough staff to fully staff the roster. PA ModerateReporting Complete30/10/2019

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.

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