Lansdowne Hospital and Rest Home
Profile & contact details
|Premises name||Lansdowne Hospital and Rest Home|
|Address||105 Botany Road Botany Downs Auckland 2010|
|Service types||Rest home care, Geriatric, Medical|
|Certification/licence name||CHT Healthcare Trust - Lansdowne Hospital and Rest Home|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||06 December 2021|
|Certification period||36 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: 24 September 2018
|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.||Interventions had not been fully documented to address the following assessed needs and risks; (i) One respite rest home resident with an indwelling catheter, minimal English and on regular food supplements; (ii) One recent hospital admission assessed as a high falls risk and at high risk of pressure injury; (iii) One hospital resident with mood changes and urinary incontinence; (iv) One rest home resident on warfarin medication and on food and fluid monitoring (noting this was being completed b… (this text has been trimmed due to space limits).||Ensure care plans fully document all interventions to address all assessed needs.||PA Moderate||Reporting Complete||18/02/2019|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Meeting minutes (e.g., quality/health and safety meetings, RN meetings) failed to reflect evidence of quality data being communicated to staff (e.g., adverse event data, internal audit results and resident surveys).||Ensure quality and risk management results (e.g., adverse event data) are communicated to staff.||PA Low||Reporting Complete||18/03/2019|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Corrective action plans that were initiated (e.g., six monthly internal audit findings) failed to indicate evidence of evaluation with sign-off.||Ensure that documentation supports evidence of corrective actions being implemented and signed off.||PA Low||Reporting Complete||18/03/2019|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||Attendance at in-service training over the past two years reflects very low attendance rates (less than 50%) at a selection of mandatory training (e.g., restraint minimisation, elder abuse and code of rights, accidents/incident reporting, cultural safety, health and safety/hazard identification).||Ensure staff meet all CHT mandatory training requirements.||PA Low||Reporting Complete||18/03/2019|
|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.||Two eyedrops in current use did not have an opening date documented on the container.||Ensure all eyedrops include document an opening date.||PA Low||Reporting Complete||18/03/2019|
|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.||(i) One of seven hospital residents did not have an initial assessment and care plan completed within 48 hours of admission. (ii) Two of seven hospital residents did not have an interRAI completed within 21 days of admission. (iii) Four of seven hospital residents did not have a long-term care plan completed within 21 days of admission. (iv) Subsequent interRAIs were not completed within the six-month timeframe for one hospital resident.||(i) Ensure all new residents have admission assessment and care plans completed within 48 hours. (ii) Ensure all residents admitted on an ARCC long-term contract have an interRAI assessment completed within 21 days of admission. (iii) Ensure all permanent residents have a long- term care plan completed within 21 days. (iv) Ensure all permanent residents have an interRAI assessment completed six monthly.||PA Low||Reporting Complete||18/03/2019|
|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).||Monitoring forms reviewed did not reflect consistent evidence of two hourly monitoring of the restraint and four hourly monitoring of the enabler.||Ensure that monitoring forms indicate residents are checked as per the monitoring schedules.||PA Low||Reporting Complete||18/03/2019|
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: 24 September 2018
Audit type:Certification Audit
- Lansdowne Hospital and Rest Home - Sep 2018 (docx, 45.25 KB)
- Lansdowne Hospital and Rest Home - Sep 2018 (pdf, 176.55 KB)
Audit type:Surveillance Audit
- Lansdowne Hospital and Rest Home - Jul 2017 (docx, 33.66 KB)
- Lansdowne Hospital and Rest Home - Jul 2017 (pdf, 133.27 KB)
Audit type:Certification Audit
- Lansdowne Hospital and Rest Home - Oct 2015 (docx, 50.5 KB)
- Lansdowne Hospital and Rest Home - Oct 2015 (pdf, 171.43 KB)
Audit type:Surveillance Audit