Northbridge Lifecare Trust Rest Home & Hospital

Profile & contact details

Premises details
Premises nameNorthbridge Lifecare Trust Rest Home & Hospital
Address 45 Akoranga Drive Northcote Auckland 0627
Total beds96
Service typesDementia care, Rest home care, Geriatric
Certification/licence details
Certification/licence nameNorthbridge Lifecare Trust - Northbridge Lifecare Trust Rest Home & Hospital
Current auditorThe DAA Group Limited
End date of current certificate/licence17 April 2024
Certification period36 months
Provider details
Provider nameNorthbridge Lifecare Trust
Street address 45 Akoranga Drive Northcote Auckland 0627
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: 23 February 2021

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
New service providers receive an orientation/induction programme that covers the essential components of the service provided.Staff interviewed advised they are provided with an orientation relevant to their role and responsibilities. However, the content of any role specific orientation activities/programmes have not been documented. Bureau staff are provided with an orientation. Records are not retained to demonstrate this has occurred or the content. Develop and implement an orientation programme that details the orientation topics new staff are required to complete as relevant to their different roles and responsibilities. Maintain records to demonstrate that staff are being provided with orientation relevant to their roles. Document the information that is required to be discussed with new bureau staff prior to their first shift. Maintain records to demonstrate that this orientation is consistently occurring. PA ModerateIn Progress
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.There is reporting of adverse events and incidents and these are totalled and reported monthly. There is not always evidence of timely analysis of this information. Ensure adverse events and incident data is analysed in a timely manner and the results communicated to staff. PA LowIn Progress
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 monitoring records for residents with restraints in use are poorly completed in three out of three applicable residents’ records sampled. Ensure staff monitor residents with restraints in use at the frequency required by the organisation and appropriate records are available to demonstrate this is occurring. PA ModerateReporting Complete21/07/2021
All buildings, plant, and equipment comply with legislation.The body protection certificates in the hospital wing are dated as due 17 September 2011. Ensure body protection certification is maintained. PA LowReporting Complete21/07/2021
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.The electronic record management system does not identify when the care-plan has been reviewed. Ensure the electronic record management system identifies exact dates when care plans are reviewed. PA LowReporting Complete21/07/2021
There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.1. The organisation’s staffing policy does not include any guidance on staffing when care home staff attend callouts for village residents. 2. There are two lines titled ‘team leader RN/EN/Senior HCA’ on the rest home morning shift roster, and the qualification of the person filling the shift is not easily identifiable at first glance. Registered health professionals and non-regulated care staff have different responsibilities and accountabilities. 3. There are 15 occasions between 23 January a… (this text has been trimmed due to space limits).1. Review staffing and skill mix to ensure adequate registered nurse oversight in the rest home and memory care unit in order to meet aged related residential care contractual requirements. 2. Review the layout of the rest home / memory care centre roster to ensure it clearly identifies the qualifications and accountabilities of the staff member filling the shift leader role. 3. Monitor staff response timeframes for answering call bells and address any variances. 4. Update the staffing and ski… (this text has been trimmed due to space limits).PA ModerateReporting Complete21/07/2021
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Despite initiatives taken by the management team to address this issue, some staff are overdue performance appraisals. Undertake annual performance appraisals for all staff. PA ModerateReporting Complete21/07/2021

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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