Profile & contact details
|Premises name||The Orchards|
|Address||123 Stanley Road Glenfield Auckland 0629|
|Service types||Rest home care, Geriatric|
|Certification/licence name||Metlifecare Limited - The Orchards|
|Current auditor||The DAA Group Limited|
|End date of current certificate/licence||09 September 2018|
|Certification period||24 months|
|Provider name||Metlifecare Limited|
|Street address||Level 4 20 Kent Street Newmarket Auckland 1023|
|Post address||PO Box 37463 Parnell Auckland 1151|
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: 08 August 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Key components of service delivery shall be explicitly linked to the quality management system.||Not all data required to inform the key components of service delivery are accurately recorded. Examples sighted relate to an assessment which showed a stage two pressure injury but documentation reporting showed this as a stage one pressure injury therefore not requiring to be reported in quality data. One approved restraint and one use of emergency restraint are not shown in the data sighted. Refer comments in 2.2.2 and 18.104.22.168 Reported unexplained bruising did not have a corresponding inciden… (this text has been trimmed due to space limits).||Provide evidence that links to all key components of service delivery are reported and recorded.||PA Moderate||Reporting Complete||02/11/2016|
|The service provides an environment that encourages good practice, which should include evidence-based practice.||Not all policies and procedures are implemented. There is evidence of poor follow up of clinical practices such as not following post-operative advice, incomplete documentation of clinical findings and behaviour management. Caregivers concerns were not always evidenced as being followed up. For example, two separate reporting of residents with bruising to a registered nurse. This was confirmed during interview with RNs but no documentation could be found related to this.||Ensure staff are working in an environment which encourages good practice by following all documented policies and procedures.||PA Moderate||Reporting Complete||02/11/2016|
|Consumers have a right to full and frank information and open disclosure from service providers.||As not all events are recorded as an incident or accident and not all events could be verified including family/whanau notification in the resident notes reviewed, open disclosure was not always evident. For example, the use of emergency restraint and two separate incidents of bruising had not been notified to the family/whanau or the nurse manager.||Provide evidence that all incidents and events are notified to the nominated next of kin.||PA Moderate||Reporting Complete||02/11/2016|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Quality improvement data collected is not a true reflection of clinical occurrences. RNs confirmed they did not write an incident form for two reports of resident bruising and in one resident file a photographed incident of bruising on a resident’s hand has not been recorded as an incident. It could not be verified that family/whanau had been notified.||Quality data information should be completed and recorded according to policy requirements.||PA Low||Reporting Complete||02/11/2016|
|A process to measure achievement against the quality and risk management plan is implemented.||The service cannot accurately measure achievement against quality and management processes owing to incomplete data recording.||Ensure all described processes are identified to measure achievements against the quality and risk management plan are implemented.||PA Moderate||Reporting Complete||02/11/2016|
|The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.||Documentation was incomplete related to clinical findings such as wound care management not being clearly described. One resident’s file did not contain a care plan and this was recovered from archives. It was not evidenced that there is effective communication with senior management and organisational management.||Provide evidence of actions taken that promotes continuity in service delivery.||PA Moderate||Reporting Complete||02/11/2016|
|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.||Ten of ten residents’ files did not contain comprehensive assessments on which to base care interventions. For example, clinical files do not always contain nutritional assessment, pain management, post-falls assessments, wound care, restraint/enablers, health risks and activities where these are indicated as being required.||Provide evidence that resident assessments are undertaken to meet policy and best practice requirements to ensure all residents’ needs are captured.||PA Moderate||Reporting Complete||02/11/2016|
|Where progress is different from expected, the service responds by initiating changes to the service delivery plan.||Short term care plans were not developed, or when developed not followed through, for all issues identified. Such as management of wounds, skin care/pressure injury, pain management and weight loss. This was identified in six of the ten files reviewed.||Provide evidence where progress is different from expected that the short term care plans are developed and acted upon in a timely manner.||PA Moderate||Reporting Complete||02/11/2016|
|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).||No assessments were undertaken for a resident who required emergency restraint. An approved restraint in another resident’s file is signed by family/whanau but no assessments could be located. As observed, the bedside rails were not on the resident’s bed at the time of audit.||Provide evidence that all restraint assessments are completed to meet requirements.||PA Low||Reporting Complete||02/11/2016|
|Approved restraint is only applied as a last resort, with the least amount of force, after alternative interventions have been considered or attempted and determined inadequate. The decision to approve restraint for a consumer should be made: (a) Only as a last resort to maintain the safety of consumers, service providers or others; (b) Following appropriate planning and preparation; (c) By the most appropriate health professional; (d) When the environment is appropriate and safe for successful … (this text has been trimmed due to space limits).||Emergency restraint was used for a resident in May 2016 who was awake during the night. The resident had previous restraint approval which according to documentation sighted in the file was ceased in March 2016 owing to it causing agitation. The reason for the use of emergency restraint was to manage agitation and does not meet policy requirements as neither the resident nor others were at risk of injury. Documentation related to this incident is incomplete and it has not been recorded in restra… (this text has been trimmed due to space limits).||Ensure all restraint process and approval requirements are clearly documented and meet policy and safe restraint use requirements.||PA Moderate||Reporting Complete||02/11/2016|
|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).||When emergency restraint was implemented in May 2016 the resident’s progress notes stated the resident was to be monitored closely. No timeframes were shown. The outcome of the restraint is not recorded. There are no details of alternative interventions being used.||Ensure that each episode of restraint is documented in sufficient detail to provide an accurate account of the indication for use, intervention, duration and outcome.||PA Low||Reporting Complete||02/11/2016|
|A restraint register or equivalent process is established to record sufficient information to provide an auditable record of restraint use.||The restraint register sighted does not show the use of emergency restraint as this was not reported to management at the time and was not included in data collection.||Ensure all restraint use is clearly recorded.||PA Low||Reporting Complete||02/11/2016|
|Results of surveillance, conclusions, and specific recommendations to assist in achieving infection reduction and prevention outcomes are acted upon, evaluated, and reported to relevant personnel and management in a timely manner.||The infection control quality data collected did not include all known infections.||Provide evidence that surveillance data includes all infection control events.||PA Low||Reporting Complete||02/11/2016|
|The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk.||Two incidences of bruising reported to registered nurses by caregivers were not recorded on incident forms. One incident of bruising on a resident’s hand sighted in resident file did not have an incident form. This does not provide evidence that when incidents are reported they are followed up via a structured corrective action process to ensure the risk of recurrence or escalation of the issue is minimised or managed, because they are not reported in the first place.||Ensure all incidents and accidents are accurately recorded.||PA High||Reporting Complete||02/11/2016|
|The organisation has a quality and risk management system which is understood and implemented by service providers.||The documented quality and risk management system is not always implemented by staff. The accuracy of data recorded could not be verified at the time of audit as inconsistencies were noted between what was evidenced in files and documentation and what was reported and recorded. For example, one resident with bruising on her hand had no incident form. An episode of diarrhoea and vomiting is not shown in quality data. Restraint reporting does not include the use of emergency restraint and a grade … (this text has been trimmed due to space limits).||Provide evidence that organisational quality and risk management systems are implemented by all service providers.||PA High||Reporting Complete||02/11/2016|
|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.||Contractual timeframes for initial assessments/care plan, interRAI assessments and the development of the long term care plans were not evidenced in up to six of the ten residents’ files reviewed. The provision of clinical follow-up, such as the removal of sutures and interventions for unexplained weight loss were not conducted to meet best practice. This places residents at high risk of clinical complications.||Provide evidence that all timeframes are met and clinical interventions demonstrate best practice standards.||PA High||Reporting Complete||02/11/2016|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||Required interventions to meet residents’ needs are not always completed or clearly identified. This was evident in 10 of 10 files reviewed and relates to pain management, post-operative follow-up, post falls management, wound care, challenging behaviour, weight loss and pressure injury management.||Provide evidence that service provision interventions are completed and consistent to ensure residents’ needs are met.||PA High||Reporting Complete||02/11/2016|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||Only one member of the kitchen staff has attended a safe food handling course.||Provide evidence of kitchen staff education in relation to safe food handling.||PA Low||Reporting Complete||06/12/2016|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||There was no documented evidence that planned activities were being provided until June 2016. Interviews with residents and management confirmed activities were provided. No individual resident activities assessments were sighted prior to May 2016.||Ensure planned activities are provided and documented to meet residents’ strengths and skills.||PA Low||Reporting Complete||06/12/2016|
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: 08 August 2017
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Partial Provisional Audit