Lester Heights Hospital
Profile & contact details
|Premises name||Lester Heights Hospital|
|Address||93 Fourth Avenue Woodhill Whangarei 0110|
|Service types||Physical, Rest home care, Geriatric, Medical|
|Certification/licence name||North Care Limited - Lester Heights Hospital|
|Current auditor||The DAA Group Limited|
|End date of current certificate/licence||01 April 2021|
|Certification period||12 months|
|Provider name||North Care Limited|
|Street address||54 Maata Road RD 18 Eltham 4398|
|Post address||54 Maata Road RD 18 Eltham 4398|
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: 20 February 2020
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Consumers are provided with safe and accessible external areas that meet their needs.||The gardens around the back of the facility look unkept and require attention. There was no shade available for residents and families. The containers used to water the dogs and for smokers do not enhance the external area.||Maintain the raised gardens, provide shade for residents and families and review the items used to provide water for the dogs and for smokers use.||PA Low||In Progress|
|Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.||The menu has not been reviewed by a registered dietitian in a timely manner following changes made to it to confirm it was appropriate to the nutritional needs of the residents.||Ensure the menu is reviewed by a registered dietitian to confirm it meets the nutritional needs of the residents.||PA Low||In Progress|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||Staff have not been provided with specific training relevant to younger people with physical disabilities since 2018.||Provide evidence that staff have been provided with in-service education relating to younger people with physical disabilities.||PA Low||In Progress|
|Each episode of restraint is evaluated in collaboration with the consumer and shall consider: (a) Future options to avoid the use of restraint; (b) Whether the consumer's service delivery plan (or crisis plan) was followed; (c) Any review or modification required to the consumer's service delivery plan (or crisis plan); (d) Whether the desired outcome was achieved; (e) Whether the restraint was the least restrictive option to achieve the desired outcome; (f) The duration of the restraint episode… (this text has been trimmed due to space limits).||The evaluation of restraint use does not include the requirements of this criterion.||Develop and implement an evaluation form that includes the requirements of the criterion.||PA Low||In Progress|
|The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.||A business plan was not available for review.||Develop and implement a business plan that includes a purpose, scope, objectives and direction of the organisation and reflects a person/family centred approach.||PA Low||In Progress|
|The organisation has a quality and risk management system which is understood and implemented by service providers.||Separate meetings are not held for the YPD residents.||Provide documented evidence that the YPD residents have regular meetings held to discuss their particular needs.||PA Low||In Progress|
|The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.||Maintenance and cleaning in the facility is not maintained to an adequate standard.||Provide evidence that: (i) walls, doors and corners that have been damaged are painted and protected and the entire facility is maintained to an adequate standard; (II) the cleanliness of the facility is maintained to an adequate standard.||PA Moderate||In Progress|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||Five out of eight activity plans were not evaluated following interRAI assessments resulting in some triggered items not being addressed in the activities care plans. No regular outings for all residents to access other community support services as preferred by residents.||Provide evidence that activity plans are evaluated/reviewed following interRAI assessments. Ensure there are opportunities for residents to access activities in the community.||PA Low||In Progress|
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: 20 February 2020
Audit type:Provisional Audit