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 2018|
|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: 25 July 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Where progress is different from expected, the service responds by initiating changes to the service delivery plan.||One rest home resident with recent pain does not have a short-term care plan commenced or their long-term plan updated to reflect this. One hospital resident with recent decline in health status does not have an updated care plan to reflect changed needs.||Ensure that all changes to residents’ health status have relevant changes made to the care plan.||PA Moderate||Reporting Complete||03/02/2016|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||One hospital resident with unstable diabetes did not have the frequency of blood sugar monitoring stated in the care plan. The same resident’s progress notes evidenced that they were receiving regular aperients but there was no bowel management stated in the care plan.||Ensure care plans fully document all interventions required.||PA Moderate||Reporting Complete||03/02/2016|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||One of nine staff files sampled does not have a completed orientation checklist.||Ensure all staff receive a comprehensive orientation and that this is documented.||PA Low||Reporting Complete||14/03/2016|
|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.||In two (one hospital and one rest home) of five care plan evaluations reviewed, the evaluations did not evidence progress of goals for all care plans.||Ensure all evaluations document progress towards stated goals.||PA Low||Reporting Complete||14/03/2016|
|The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code.||Three of the six complaints for 2015 do not have documented evidence that the outcome of the complaint was fed back to the complainant.||Ensure that the complainant is provided with the outcome for all complaints.||PA Low||Reporting Complete||14/03/2016|
|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.||One of three hospital residents admitted since 1 July 2015 on a long-term contract, did not have an InterRAI assessment completed within 21 days of admission.||Ensure all residents admitted on a long-term contract have an InterRAI assessment completed within 21 days of admission.||PA Low||Reporting Complete||14/03/2016|
|The needs, outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning.||Three of nine files reviewed (all hospital) did not have the InterRAI assessment summary comments completed to fully inform the care plans.||Ensure that the InterRAI assessment is fully completed including detailed comments.||PA Low||Reporting Complete||14/03/2016|
|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) During the observed medication round the registered nurse left the unlocked medication trolley in the dining room at lunchtime and left the room to get something from the treatment room. (ii) Weekly controlled drug checks have not always occurred in the rest home.||(i) Ensure medications are stored safely at all times including during medication rounds. (ii) Ensure weekly controlled drugs checks occur.||PA Moderate||Reporting Complete||17/01/2018|
|The facilitation of safe self-administration of medicines by consumers where appropriate.||The resident that self-administers medication did not have a competency assessment completed.||Ensure all residents that self-administer medications have a current competency assessment.||PA Low||Reporting Complete||17/01/2018|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||(i) Cool stored and freezer temperatures had not been recorded for the five days prior to the audit. (ii) There was food in the cool store and pantry that was not dated.||(i) Ensure cool store and freezer temperatures are recorded daily as per policy. (ii) Ensure all stored food is dated.||PA Low||Reporting Complete||17/01/2018|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||(i)One rest home resident care plan sampled did not address shortness of breath or the need for an air mattress; (ii) one rest home resident file did not address the falls risk. (iii) One hospital resident care plan sampled did not address aspiration risk or the interventions related to the resident being a diabetic on insulin.||(i)-(iii) Ensure care plans fully document all interventions required.||PA Moderate||Reporting Complete||17/01/2018|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i) Eight of twelve minor wounds did not have a comprehensive assessment. (ii) One of the four current pressure injuries did not have the grade or depth documented. (iii)Three of twelve minor wounds and one of four pressure injuries did not have a documented wound management plan. (iv) The one resident file sampled for a resident on the interim orthopaedic scheme had an instruction for a blood test in the hospital discharge summary. This had not occurred.||(i), (ii) and (iii). Ensure all wounds have a comprehensive assessment and management plan documented. (iv) Ensure all cares/procedures required in discharge summaries occur, either by the service or as arranged by the service by another agency.||PA Moderate||Reporting Complete||17/01/2018|
|The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk.||Two accident/incident forms were not completed for bruising incidents that were documented in the resident’s progress notes.||Ensure that accident/incident forms are completed for all residents’ accident/incidents that occur.||PA Low||Reporting Complete||14/03/2018|
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: 25 July 2017
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
- Lansdowne Hospital and Rest Home - Jun 2014 (docx, 72.2 KB)
- Lansdowne Hospital and Rest Home - Jun 2014 (pdf, 472.18 KB)
Audit type:Certification Audit
Audit type:Surveillance Audit; Verification Audit