Leigh Road Cottage
Profile & contact details
|Premises name||Leigh Road Cottage|
|Address||582 Leigh Road Whangateau 0985|
|Service types||Dementia care|
|Certification/licence name||Agape Care Warkworth Limited - Leigh Road Cottage|
|Current auditor||The DAA Group Limited|
|End date of current certificate/licence||07 March 2021|
|Certification period||36 months|
|Provider name||Agape Care Warkworth Limited|
|Street address||582 Leigh Road Whangateau 0985|
|Post address||52A King George Avenue Espom Auckland 1023|
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: 23 January 2018
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|The service develops and implements policies and procedures that are aligned with current good practice and service delivery, meet the requirements of legislation, and are reviewed at regular intervals as defined by policy.||Approximately three quarters of the policies and procedures have not been reviewed and updated. The medicine policy has sections that are not applicable to dementia level care.||All policies and procedures are reviewed and updated, including reference to current legislation, as per the timeframe set out in the policy.||PA Low||In Progress|
|The appointment of appropriate service providers to safely meet the needs of consumers.||(i)There was no evidence in the five files of police checking; (ii) three files had no current performance appraisals (the other two staff member are recently employed and therefore not due); (iii) there was no evidence in two files of reference checking; (iv) there was no evidence in two files of position descriptions.||Human resources processes are to be completed for all staff including police checking, reference checks, position descriptions and performance appraisals.||PA Moderate||Reporting Complete||06/08/2018|
|The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.||(i)The shower floor in the Takahe wing slopes towards to the door, and as a result water is damaging the door and potentially the floor and walls. (ii)The flower gardens surrounding the facility are overgrown and need weeding. (iii) External areas of the building have paint worn off, the roofing is showing rust and there is moss on the south walls.||(i)Provide a timeframe for replacing the shower door and rectifying the way the water flows. (ii)Weed and maintain the flower gardens. (iii)Ensure the exterior of the facility is maintained.||PA Moderate||Reporting Complete||06/08/2018|
|The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code.||There was no written documentation available for any of the complaints entered in the complaints register to evidence compliance with Right 10 of the Code. The register does not provide for entering timeframes relating to responding to complainants.||Provide documented evidence that all complaints received meet Right 10 of the Code.||PA Low||Reporting Complete||01/10/2018|
|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.||An ‘audit’ (count) of the controlled drugs is conducted monthly, rather than the required weekly. There has not been a required six-monthly controlled drug stocktake in the last year.||Ensure a count of controlled drugs is undertaken weekly and that a controlled drug stock take is undertaken six monthly.||PA Low||Reporting Complete||01/10/2018|
|Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.||The summer menu is now in use and this has not been reviewed by a qualified dietitian.||Ensure the summer menu is reviewed by a qualified dietitian.||PA Low||Reporting Complete||18/12/2018|
|Consumers are provided with safe and accessible external areas that meet their needs.||(i)The concrete path leading from Hi Hi wing to the outside is broken, uneven and sloping. (ii)The retaining wall near the raised gardens is approximately 1.5 metres high and can easily be accessed by residents, who could walk along the top of the wall and fall on to the concrete below.||(i)Provide a timeframe for repair of the concrete path (ii)Provide a timeframe for making the area leading to the top of the retaining wall safe.||PA Moderate||Reporting Complete||18/12/2018|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||The RN/ infection control coordinator has not undertaken ongoing education specific to infection prevention and control. The Activities Officer has not received training to support her to assess, implement and evaluate the activities programme.||Ensure training is provided to the RN to assist her in her role as ICN. Ensure the Activities Officer has the knowledge and skills to ensure she can provide assessment, implementation and evaluation of the activities programme.||PA Low||Reporting Complete||17/06/2019|
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: 23 January 2018
Audit type:Certification Audit
Audit type:Provisional Audit