Jack Inglis Friendship Hospital

Profile & contact details

Premises details
Premises nameJack Inglis Friendship Hospital
Address 15A Courtney Street Motueka 7120
Total beds74
Service typesDementia care, Rest home care, Geriatric, Medical
Certification/licence details
Certification/licence nameFOMHT Health Services Limited - Jack Inglis Friendship Hospital
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence21 July 2021
Certification period24 months
Provider details
Provider nameFOMHT Health Services Limited
Street address 15A Courtney Street Motueka 7120
Post address

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: 20 May 2019

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include: (a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk; (b) A process that addresses/treats the risks associated with service provision is developed and im… (this text has been trimmed due to space limits).(i) The health and safety committee does not have representation of all staff, and only includes the management team. (ii) New hazards have not been identified and included in the register to ensure strategies are implemented to minimise, eliminate or isolate. (i) Ensure that the health and safety committee includes staff representation. (ii) Ensure that the hazard register includes all identified hazards. PA ModerateReporting Complete10/12/2019
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Ensure that staff complete at least eight hours training a year. Ensure that staff maintain a minimum eight hours training. PA LowReporting Complete10/12/2019
There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.The clinical manager has resigned from her current position but is still in the position and has current responsibility for clinical supervision. The recruitment process is in planning stages. There are number of corrective actions around service delivery. This is work in progress. The CM is already covering RN shortages/sick leave until two RNs obtain work visas’. The current RN team is young and requires support and supervision. Furthermore, this audit identified several clinical findings… (this text has been trimmed due to space limits).Ensure that the clinical manager position is replaced in a timely manner and clinical supervision continues to be maintained. PA ModerateReporting Complete10/12/2019
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.(i) There was no diabetic management plan in place for the rest home respite resident who was an insulin dependent diabetic. (ii) Rest home younger person under ACC was assessed at high risk of falls, however, the care plan did not reflect falls prevention strategies for high falls risk. The same resident did not have any documented interventions for hip pain post fall, requiring GP treatment and analgesia. (iii) Another rest home resident did not have a documented pressure injury prevention … (this text has been trimmed due to space limits).Ensure interventions are documented to meet the resident support and needs. PA ModerateReporting Complete10/12/2019
Each episode of restraint is documented in sufficient detail to provide an accurate account of the indication for use, intervention, duration, its outcome, and shall include but is not limited to: (a) Details of the reasons for initiating the restraint, including the desired outcome; (b) Details of alternative interventions (including de-escalation techniques where applicable) that were attempted or considered prior to the use of restraint; (c) Details of any advocacy/support offered, provided o… (this text has been trimmed due to space limits).Restraint and enabler monitoring records were incomplete and there were gaps in monitoring forms from six hours to two days. Ensure that restraint and enabler monitoring is completed as planned. PA LowReporting Complete10/12/2019
Services conduct comprehensive reviews regularly, of all restraint practice in order to determine: (a) The extent of restraint use and any trends; (b) The organisation's progress in reducing restraint; (c) Adverse outcomes; (d) Service provider compliance with policies and procedures; (e) Whether the approved restraint is necessary, safe, of an appropriate duration, and appropriate in light of consumer and service provider feedback, and current accepted practice; (f) If individual plans of care/… (this text has been trimmed due to space limits).The organisation-wide quality review of restraint use does not identify a thorough review of restraint minimisation practises. Ensure that a thorough quality review of restraint minimisation occurs, and that it considers all components listed in this criterion. PA LowReporting Complete07/01/2020

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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