Profile & contact details
|Premises name||Lexall Care|
|Address||19 Denver Avenue Sunnyvale Auckland 0612|
|Service types||Rest home care, Geriatric, Medical|
|Certification/licence name||Lexall Limited|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||26 June 2018|
|Certification period||36 months|
|Provider name||Lexall Limited|
|Street address||19 Denver Avenue Sunnyvale Auckland 0612|
|Post address||PO Box 100347 North Shore Auckland 0745|
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: 16 November 2016
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i) The care plans for two residents with unintentional weight loss recorded (one resident with 3kg weight loss in three months and one resident with 7kg weight loss over six months) had not been updated to reflect the nutritional and dietary interventions that were observed currently being implemented. (ii) The care plan of one hospital resident with a stage-2 pressure injury had not been updated to reflect the pressure injury and appropriate pressure relieving management interventions that we… (this text has been trimmed due to space limits).||(i-ii) Ensure that care plans are updated when there is a change in resident need. (iii) Ensure that wound assessment and management plans are fully documented and followed and that all wounds have interventions documented in either a short-term care plan with regular documentation reviews, or in a long-term care plan.||PA Moderate||Reporting Complete||30/05/2017|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||There was no documentation on file to support acknowledgement, investigation or follow up of complaints.||Ensure all complaints registered in the complaint log include documentation to support follow up action.||PA Low||Reporting Complete||31/08/2015|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||There was no evidence of resident meetings or satisfaction surveys being undertaken in the last two years.||Ensure satisfaction surveys and resident meetings are undertaken to gather feedback on the service provided.||PA Low||Reporting Complete||31/08/2015|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||The education plan for 2013-2014 was not fully completed. Cultural, continence, sexuality and intimacy and chemical safety training have not been provided in the last two years.||Ensure the education plan is completed as per schedule and all compulsory training is undertaken by staff.||PA Low||Reporting Complete||31/08/2015|
|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 medication fridges were not being monitored or documented.||Ensure temperatures of the medication fridges are monitored and recorded||PA Low||Reporting Complete||31/08/2015|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||Wound assessments reviewed were incomplete with no description of the wound, no skin tear category stated and in some incidences no wound site stated.||Ensure wound assessment documentation is fully completed for all wounds.||PA Low||Reporting Complete||31/08/2015|
|In assessing whether restraint will be used, appropriate factors are taken into consideration by a suitably skilled service provider. This shall include but is not limited to: (a) Any risks related to the use of restraint; (b) Any underlying causes for the relevant behaviour or condition if known; (c) Existing advance directives the consumer may have made; (d) Whether the consumer has been restrained in the past and, if so, an evaluation of these episodes; (e) Any history of trauma or abuse, whi… (this text has been trimmed due to space limits).||The four files reviewed (two restraint and two enablers), assessments were not fully completed.||Ensure assessments are completed||PA Low||Reporting Complete||31/08/2015|
|Each episode of restraint is documented in sufficient detail to provide an accurate account of the indication for use, intervention, duration, its outcome, and shall include but is not limited to: (a) Details of the reasons for initiating the restraint, including the desired outcome; (b) Details of alternative interventions (including de-escalation techniques where applicable) that were attempted or considered prior to the use of restraint; (c) Details of any advocacy/support offered, provided o… (this text has been trimmed due to space limits).||The four care plans reviewed did not detail that a restraint or enabler was in use or the associated risks/minimisation strategies. Monitoring was not documented as undertaken two hourly as per policy.||Ensure all restraint documentation is completed within set timeframes.||PA Moderate||Reporting Complete||31/08/2015|
|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.||(i) Two of three resident files reviewed where an InterRAI assessment was contractually required, one had not been completed and two had been completed outside of the required timeframes. (ii) Three permanent resident files reviewed did not evidence that activity plan evaluations had been completed monthly and six monthly as per policy.||(i)-(ii) Ensure that InterRAI assessments are completed within the required timeframes and/or when there is a change in the resident’s condition and that activity plans are reviewed within the required timeframes.||PA Moderate||In Progress|
|Consumers have a right to full and frank information and open disclosure from service providers.||Five out of fifteen accident/incident reports, which included two pressure injuries, two skin tears and one bruise incident, did not indicate that families were informed.||Ensure that documentation on accident/incident forms reflects families being kept informed following an accident/incident.||PA Low||Reporting Complete||30/05/2017|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||i) Internal audit results that identify findings do not consistently include corrective action plans. ii) Quality initiatives developed in 2016 around the activities programme and medication management have not been evaluated or signed off.||Corrective action plans are required where internal audit results reflect a need for improvement. Ensure quality activities are evaluated and signed off.||PA Low||Reporting Complete||30/05/2017|
|The appointment of appropriate service providers to safely meet the needs of consumers.||Staff files reviewed confirmed evidence of reference checking in only one of five files. The clinical manager reported that reference checking is completed for all applicants prior to an appointment being made, but she was unable to locate the paperwork.||Ensure that there is documented evidence to confirm reference checks are completed for new staff.||PA Low||Reporting Complete||30/05/2017|
|There is a document control system to manage the policies and procedures. This system shall ensure documents are approved, up to date, available to service providers and managed to preclude the use of obsolete documents.||Some policies are behind schedule for a two-yearly review (eg, pressure injury prevention and management, bladder care, blood accidents, bowel care). A policy and procedure around the implementation of InterRAI has not been developed.||Ensure policies are reviewed as per the document review schedule. InterRAI procedures are required.||PA Low||Reporting Complete||20/06/2017|
|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) Two residents on warfarin did not have a signed warfarin medication order. A telephone verbal order from the GP practice based on the INR result is received by the RN on duty. Verbal orders received were not documented on the medication chart but were documented on a ‘Warfarin INR chart’. The chart was evidenced to be signed by the RN but a GP signature and registration number was not included in the order. (ii) Standing orders have not been reviewed annually. Last date of review occur… (this text has been trimmed due to space limits).||(i) Ensure that all medications orders are signed and dated by a GP. (ii) Ensure that Standing Orders are reviewed as per MOH medication guidelines. (iii) Transcribing of medications on medication signing charts is to cease.||PA Moderate||Reporting Complete||20/06/2017|
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: 16 November 2016
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Partial Provisional Audit
Audit type:Certification Audit
Audit type:Surveillance Audit