Leighton House

Profile & contact details

Premises details
Premises nameLeighton House
Address 2 Cheeseman Road Inner Kaiti Gisborne 4010
Total beds50
Service typesRest home care, Geriatric, Medical
Certification/licence details
Certification/licence nameLeighton House Limited
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence10 July 2024
Certification period36 months
Provider details
Provider nameLeighton House Limited
Street addressLeighton House 2 Cheeseman Road Inner Kaiti Gisborne 4010
Post address14 Browning Crescent Stoke Nelson 7011

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 November 2022

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.(a) The presence of a stage 2 facility acquired pressure injury (rest home resident) had not been reported on an accident/incident form and was not linked to the long-term care plan. (b) Ten of twenty-two neurological observations commenced for unwitnessed falls had not been completed as per protocol for 24 hours. (c) There were no implemented or documented interventions in place for one rest home resident with over 5% weight loss in one month. (a) Ensure pressure injuries are reported on an accident/incident form and are documented into the long-term care plan. (b) Ensure neurological observations are completed as per protocol for unwitnessed falls. (c) Ensure interventions are implemented/documented for unintentional weight loss. PA ModerateIn Progress
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.There were no documented interventions for three rest home residents; (a) one resident with back pain requiring ‘as required’ analgesia and GP reviews, (b) management of seizures for resident with a recent admission for grand mal seizure and (c) there was no diabetic management plan for a resident on insulin. Ensure supports/interventions are documented to support the resident’s current health status. PA LowReporting Complete16/02/2022
Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services.The service does not have sufficient numbers of registered nurses to have a RN on duty at all times as per the ARRC contract D17.4 a. i. Ensure a registered nurse is on duty at all times to meet the requirements of the ARC contract D17.4 a. i. PA LowIn Progress
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.Corrective action plans and evidence or resolution of issues identified through clinical audits have not been completed in a timely manner for those completed in 2021. Document corrective action plans for clinical audits in a timely manner, and evidence resolution of issues. PA LowReporting Complete21/03/2024
Key components of service delivery shall be explicitly linked to the quality management system.Complaints are not linked to the quality programme in order for improvements to be made. Link complaints into the quality programme so that improvements can be made. PA LowReporting Complete21/03/2024
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.Six of 14 medication charts did not record an allergy status. Ensure all medication charts identify an allergy status. PA ModerateReporting Complete21/03/2024
Service delivery plans demonstrate service integration.There was no documented evidence the resident/relative had been involved in the development and evaluation of long-term care plans. Ensure there is documented evidence of resident/relative involvement in care planning. PA LowReporting Complete21/03/2024

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. 

From 1 June 2009 to 28 February 2022 rest homes were audited against the Health and Disability Services Standards NZS 8134:2008. These standards have been updated, and from 28 February 2022 rest homes are audited against Ngā Paerewa Health and Disability Services Standard NZS 8134:2021.

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 Ngā Paerewa Health and Disability Services Standard.

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 reports

Audit date: 23 November 2022

Audit type:Surveillance Audit

Audit date: 11 May 2021

Audit type:Certification Audit

Audit date: 04 June 2019

Audit type:Surveillance Audit

Audit date: 03 May 2017

Audit type:Certification Audit

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