Maida Vale Retirement Village

Profile & contact details

Premises details
Premises name	Maida Vale Retirement Village
Address	20 Pohutukawa Place Bell Block New Plymouth 4312
Total beds	93
Service types	Physical, Medical, Rest home care, Geriatric

Certification/licence details
Certification/licence name	Avatar Management Limited - Maida Vale Retirement Village
Current auditor	The DAA Group Limited
End date of current certificate/licence	20 May 2024
Certification period	36 months

Provider details
Provider name	Avatar Management Limited
Street address	20 Pohutukawa Place Bell Block New Plymouth 4312
Post address	PO Box 7015 Fitzroy New Plymouth 4341

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: 17 January 2023

Outcome required	Found at audit	Action required	Risk rating	Action status	Date action reported complete
Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided.	Records are not available to demonstrate staff are completing role-specific orientation. This was missing from at least eight out of 12 staff records where this aspect was sampled.	Ensure all staff complete role-specific orientation requirements within the applicable timeframes and that records are retained to demonstrate this.	PA Moderate	Reporting Complete	19/09/2023
An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.	Complaints are not being received by the person delegated to receive the complaint in a timely way, nor being addressed within the timeframes required by the Code of Rights. All relevant information related to the complaint investigation and corrective action plan and follow-through of actions was not available to track the progress and outcome. Formal closure of the complaint with documented notification to the complainant, including their right to access the HDC was not evident.	The complaints register provides a clear record of the date the complaint was received, the date the complaint manager receives the complaint, all relevant dates throughout the investigation process and the formal closure of the complaint. All relevant information, including correspondence, corrective action plans and completion of actions are maintained in a format that can be easily tracked.	PA Moderate	Reporting Complete	23/12/2021
Key components of service delivery shall be explicitly linked to the quality management system.	Although the quality and risk committee have a fixed agenda covering most relevant areas of quality and risk, it was not evident that all areas are being included for discussion at the bi-monthly meetings. There was an inconsistent approach to information reported to this group in the way of clinical and other indicators. The audit programme is not yet well established with good analysis of results data. There is no restraint committee/forum to overview restraint and enabler use. Discussions a… (this text has been trimmed due to space limits).	Key components of service delivery are linked to the quality management system through the quality and risk committee, as described in the meeting minutes template.	PA Moderate	Reporting Complete	23/12/2021
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.	While corrective actions are being completed following straight forward events/incidents and low-level complaints, not all corrective actions are reflecting all the issues raised within a complaint or an incident and there is limited and inconsistent evidence to indicate that all actions are defined, followed-through and formally closed off as having been completed.	Corrective action plans address all areas needing improvement, are completed within timeframes agreed and are reviewed to ensure that areas for improvement have been addressed.	PA Moderate	Reporting Complete	23/12/2021
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.	Data reviewed and interviews with staff indicated that not all required mandatory training is being completed as and when required. Documenting of all training completed in a consistent and complete way was not evident. Records showed, for example, that of the 84 people who should have completed infection prevention and control training in 2020, 23 had done so. There is an electronic process to complete performance appraisals. Records indicated that 29 staff out of the 49 staff due appraisals … (this text has been trimmed due to space limits).	All mandatory training occurs as required and there is an accurate record of all training completed. Performance appraisals are completed for all staff as and when due.	PA Moderate	Reporting Complete	23/12/2021
There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.	A number of residents and staff expressed concern in relation to insufficient staff and the ability to provide adequate and timely care to residents. The work to review rosters, acuity and workload is acknowledged. At the time of audit there were several staff away on planned and unplanned leave and the ability to fill shifts with ‘casual’ staff was not always possible. At Mountain View the layout of the facility is a challenge for staff and this is particularly evident during the night. There i… (this text has been trimmed due to space limits).	Staffing is reviewed in consultation with the clinical leadership team to ensure there is adequate cover on all shifts across the facility, considering the facility layout and resident acuity.	PA Moderate	Reporting Complete	23/12/2021
Service providers have access to designated areas for the safe and hygienic storage of cleaning/laundry equipment and chemicals.	Sluice rooms and cleaning and laundry equipment and chemical storage areas are not always being secured for residents’ safety.	Ensure designated areas for the storage of cleaning/laundry equipment and chemicals and for management of hazardous waste are secure at all times.	PA Low	Reporting Complete	23/12/2021
An appropriate 'call system' is available to summon assistance when required.	Managers, staff, residents and family members informed the call bell system is not always reliable when residents push a button for assistance.	Ensure the residents’ call bell system is reliable and enables residents to summon assistance when required.	PA Moderate	Reporting Complete	23/12/2021
Services conduct comprehensive reviews regularly, of all restraint practice in order to determine: (a) The extent of restraint use and any trends; (b) The organisation's progress in reducing restraint; (c) Adverse outcomes; (d) Service provider compliance with policies and procedures; (e) Whether the approved restraint is necessary, safe, of an appropriate duration, and appropriate in light of consumer and service provider feedback, and current accepted practice; (f) If individual plans of care/… (this text has been trimmed due to space limits).	There is not currently a restraint minimisation committee; therefore, comprehensive reviews of restraint use that cover (a) to (h) of the standard are not occurring as required.	An appropriate restraint minimisation committee/group is established and completes monitoring and quality review of restraint minimisation practices to meet the requirements of the standard.	PA Low	Reporting Complete	23/12/2021
Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services.	There is one registered nurse on duty overnight who works across the two buildings where hospital level care residents live.	Have a registered nurse on duty at all times in each building where hospital level care is provided.	PA Moderate	Reporting Complete	20/12/2023
Health care and support workers shall have the opportunity to discuss and review performance at defined intervals.	Approximately two thirds of staff and managers are overdue their annual performance appraisals. Managers admit they struggle to complete these in a timely manner.	Undertake annual performance appraisals for staff.	PA Moderate	Reporting Complete	19/01/2024

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: 17 January 2023

Audit type:Surveillance Audit

Audit date: 23 February 2021

Audit type:Certification Audit

Audit date: 05 March 2019

Audit type:Surveillance Audit

Audit date: 07 March 2017

Audit type:Certification Audit

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