Opunake Cottage Rest Home

Profile & contact details

Premises details
Premises name	Opunake Cottage Rest Home
Address	1 Layard Street Opunake 4616
Total beds	21
Service types	Rest home care

Certification/licence details
Certification/licence name	Opunake Districts Rest Home Trust - Opunake Cottage Rest Home
Current auditor	The DAA Group Limited
End date of current certificate/licence	24 May 2024
Certification period	36 months

Provider details
Provider name	Opunake Districts Rest Home Trust
Street address	1 Layard Street Opunake 4616
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: 03 October 2022

Outcome required	Found at audit	Action required	Risk rating	Action status	Date action reported complete
Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.	The menu in use was not reviewed by a dietitian within the past two years.	Provide evidence of a current menu review by a dietician.	PA Low	Reporting Complete	28/07/2021
The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.	The strategic plan including the purpose, values, scope, direction and goals of the objectives and direction of the organisation has not been reviewed since 2018 by the trust board. There is no current up to date strategic plan with objectives set as yet for 2021 to 2022. The strategic plan has not been signed off by the trust board to be effectively implemented by the organisation.	To ensure the current strategic plan is reviewed, analysed and updated for 2021 – 2022 and signed off by the chairperson or a designated board member when approved prior to implementation.	PA Moderate	Reporting Complete	28/07/2021
The organisation is managed by a suitably qualified and/or experienced person with authority, accountability, and responsibility for the provision of services.	The FCM appointed to the manager role in 2018 has not completed the eight hours of minimum management training required annually over the last two years.	To ensure the FCM attends and maintains records of any annual training attended in relation to aged care management as per the service agreement.	PA Moderate	Reporting Complete	28/07/2021
The service develops and implements policies and procedures that are aligned with current good practice and service delivery, meet the requirements of legislation, and are reviewed at regular intervals as defined by policy.	The service has policies and procedures in place. Apart from one human resource manual being reviewed there is not a current plan to ensure documents are controlled and are reviewed in a timely manner as defined in policy and to meet the requirements of legislation.	To ensure the policies and procedures are controlled documents and reviewed in a timely manner to meet legislative requirements.	PA Moderate	Reporting Complete	19/10/2021
The needs, outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning.	There were seven overdue interRAI reassessments. The overdue interval ranged from five to eight months.	Provide evidence that all interRAI reassessments are completed in a timely manner.	PA Moderate	Reporting Complete	19/10/2021
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.	There is currently no documented control system to manage policies and procedures No policies and procedures have been reviewed since 2017 and 2018. The quality manager has been appointed specifically to manage the payroll and to undertake the human resources manual review which has just been completed and is now awaiting approval from the board to be implemented.	To ensure there is a document control system that has been implemented. The system shall ensure policies and procedures are up-to-date, available and manged to preclude the use of obsolete documents.	PA Moderate	Reporting Complete	17/03/2022
Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is undertaken by suitably qualified and/or experienced service providers who are competent to perform the function.	The was no evidence to demonstrate that the HCAs who were completing the wound care management and evaluation of wound care plans have received appropriate training in wound care management and evaluation. There was no evidence to demonstrate annual competency evaluation for the interRAI assessor.	Provide evidence that the HCAs who are responsible for completing wound care management have received appropriate training. Provide evidence that the interRAI assessor has completed the annual competency assessment.	PA Low	Reporting Complete	17/03/2022
Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome.	The wound evaluation documentation was not completed consistently as per organisation’s policies and procedures.	Provide evidence of documented evaluation of wound care plans.	PA Low	Reporting Complete	17/03/2022
The organisation has a clearly defined and documented infection control programme that is reviewed at least annually.	There was no evidence of a documented and annually reviewed infection control programme.	Provide evidence of a documented infection control programme that is annually reviewed.	PA Low	Reporting Complete	17/03/2022
An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.	The complaints manual was reviewed. A copy of the complaints process was reviewed in the front of the folder to guide staff. Two written complaints have been received in the last twelve months. The register which is maintained by the FCM does not reflect these complaints and the register has had not been updated since 04 February 2019.	To ensure the complaints register is up-to-date and maintained to meet the requirements of the Code and the organisation’s complaints policy.	PA Low	Reporting Complete	04/11/2022
Service providers ensure competent health care and support workers manage medication including: receiving, storage, administration, monitoring, safe disposal, or returning to pharmacy.	A number of staff administering medications were not competent to do so.	Provide evidence that all staff who administer medications are competent to do so.	PA Moderate	Reporting Complete	02/05/2023
Service providers shall ensure that there is a pandemic or infectious disease response plan in place, that it is tested at regular intervals, and that there are sufficient IP resources including personal protective equipment (PPE) available or readily accessible to support this plan if it is activated.	The infection control programme is documented, however has not been reviewed in the past year.	Provide evidence the infection control programme is reviewed annually.	PA Moderate	Reporting Complete	02/05/2023
Planned review of a person’s care or support plan shall: (a) Be undertaken at defined intervals in collaboration with the person and whānau, together with wider service providers; (b) Include the use of a range of outcome measurements; (c) Record the degree of achievement against the person’s agreed goals and aspiration as well as whānau goals and aspirations; (d) Identify changes to the person’s care or support plan, which are agreed collaboratively through the ongoing re-assessment and review … (this text has been trimmed due to space limits).	There is no documentation in place to evidence a planned review/evaluation of the care the resident receives has been undertaken. Where progress is different than expected there is no documentation in the care plan that verifies changes have been made.	Provide evidence that there is documentation in place to evidence a planned review of residents’ care plan occurs. Where progress is different from that expected changes are initiated in collaboration with the person receiving the service and whānau.	PA Moderate	Reporting Complete	06/06/2023
Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care.	Most policy and procedures documents are out of date, have not been reviewed since 2018, and do not reflect the requirements of the Ngā Paerewa: Health and Disability Sector Standard. The quality and risk management system collects data/information in respect of quality indicators, but the data/information generated is not used to support improvements to service delivery.	Policy and procedure documents are reviewed to ensure they meets the requirements of the Ngā Paerewa: Health and Disability Sector Standard and a process is put in place to ensure policies and procedures are reviewed in a timely manner. Implement a system to utilise the data/information generated from quality activities to inform meaningful corrective action to improve service delivery.	PA Moderate	Reporting Complete	06/06/2023

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: 03 October 2022

Audit type:Surveillance Audit

Audit date: 25 February 2021

Audit type:Certification Audit

Audit date: 04 February 2019

Audit type:Surveillance Audit

Audit date: 20 July 2017

Audit type:Certification Audit

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