Leslie Groves Hospital

Profile & contact details

Premises details
Premises nameLeslie Groves Hospital
Address 321 Taieri Road Halfway Bush Dunedin 9010
Total beds71
Service typesPsychogeriatric, Geriatric, Medical, Dementia care
Certification/licence details
Certification/licence nameLeslie Groves Society of St John's (Roslyn) - Leslie Groves Hospital
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence13 September 2021
Certification period36 months
Provider details
Provider nameLeslie Groves Society of St John's (Roslyn)
Street address 321 Taieri Road Halfway Bush Dunedin 9010
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: 14 January 2020

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
The use of enablers shall be voluntary and the least restrictive option to meet the needs of the consumer with the intention of promoting or maintaining consumer independence and safety.i) Monitoring forms have not been completed for all periods of usage. ii) Consent has not been reviewed as per the policy. i) Resident using restraint is reassessed and approval is completed as per policy for restraint. ii) Resident is reviewed as to the need of restraint due to changes in health status. PA LowReporting Complete20/07/2020
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.Monitoring forms for repositioning, toileting schedules and checks were not always completed. Ensure monitoring forms are maintained as per care plan intervention. PA LowReporting Complete20/07/2020
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.Temperatures of the medication rooms were not monitored or recorded. The temperature of the medication rooms are monitored daily at the warmest time of the day. PA LowReporting Complete20/07/2020
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.No evidence of education sessions in 2018 or 2019 around advocacy, falls minimisation, continence, pressure injury prevention, health and safety, chemical safety, the aging process and sexuality and intimacy. Ensure outstanding education sessions are included in the 2020 education planner. PA ModerateReporting Complete20/07/2020
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).The hazard register has not been reviewed since 2018. Ensure the hazard register is reviewed at least annually. PA LowReporting Complete20/07/2020
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.(i) There have been no clinical, HR or environmental audits completed for 2019. (ii) Quality data of falls and infection rates are not consistently discussed at unit meetings. Staff were unable to describe this during interview. (iii) There has been no resident survey completed in 2019. (i) Ensure internal audits are completed according to the schedule. (ii) Ensure discussions held in meetings around quality data are captured in the meeting minutes. (iii) Ensure a resident survey is performed in 2020 in line with the ARC agreement. PA ModerateReporting Complete20/07/2020
The organisation has a quality and risk management system which is understood and implemented by service providers.(i) There was no documented quality plan for 2019. )ii) There is no documented strategic plan in place since 2018. (i)-(ii). Ensure there are strategic, quality and risk management plans in place to evidence quality improvement and direction. PA LowReporting Complete20/07/2020
Consumers have a right to full and frank information and open disclosure from service providers.Notification to relatives of two dementia residents and one psychogeriatric resident were not documented, and the reason for not notifying relatives was not evident in the electronic adverse event form or the progress notes. Ensure the notification (or reason why not) is documented following adverse events. PA LowReporting Complete20/07/2020
An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.There was no documented complaints register for 2019. Ensure the complaints register is maintained for 2020. PA LowReporting Complete20/07/2020
The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code.Two of two complaints received in 2019 had no supporting documentation of response in a timely manner. Ensure all complaints received are acknowledged and followed up within timeframes. PA LowReporting Complete20/07/2020
New service providers receive an orientation/induction programme that covers the essential components of the service provided.i) No role-specific orientation documented for two of six staff files including the clinical manager, a unit manager and the occupational therapist. ii) Three of six staff files reviewed did not have a current appraisal. Ensure all staff complete orientation documentation, and staff appraisals are completed according to policy. PA LowReporting Complete26/08/2020
All buildings, plant, and equipment comply with legislation.(i) Hot water temperatures have not been monitored for the month of December 2019. (ii) Medical equipment has not been assessed or calibrated annually. (iii) There was no current building warrant of fitness in place. (i) Ensure hot water temperatures and equipment is monitored or calibrated as per legislation. (ii) Ensure all medical equipment is assessed and calibrated annually. (iii) Ensure a current building warrant of fitness for the hospital is obtained. PA ModerateReporting Complete26/08/2020

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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