Otatara Heights Residential Care
Profile & contact details
|Premises name||Otatara Heights Residential Care|
|Address||8 Kotuku Place Taradale Napier 4112|
|Service types||Psychiatric, Physical, Rest home care|
|Certification/licence name||Taslin NZ Limited - Otatara Heights Residential Care|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||18 November 2020|
|Certification period||36 months|
|Provider name||Taslin NZ Limited|
|Street address||8 Kotuku Place Taradale Napier 4112|
|Post address||10a Goldsmith Terrace Hospital Hill Napier 4110|
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: 05 April 2019
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|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.||Assessment tools and processes, including interRAI, have not been updated at the six-monthly intervals. There was also limited evidence of short term plans being used.||Reassessment processes are completed within contractual timeframes and when a person’s condition changes. The newly established system for the use of short term care plans when indicated is implemented.||PA Moderate||Reporting Complete||20/03/2018|
|Key components of service delivery shall be explicitly linked to the quality management system.||Only one of four quality and risk management committee meetings scheduled up to September 2017 have occurred thus far; therefore, some components of service delivery such as event reporting, complaints management, infection control, health and safety, and restraint minimisation are not being explicitly linked to the organisational quality management system.||Re-implement the system which enables key components of service delivery and organisational management to be explicitly linked to the quality management system.||PA Low||Reporting Complete||31/07/2018|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Service delivery plans do not include an activity related goal or action plan that will be evaluated alongside other components of the service delivery plan. Mental health plans do not specifically include relapse prevention plans/early warning signs and service delivery plans for young people with disabilities do not demonstrate lifestyle planning.||To ensure holistic services are delivered, all service delivery plans require a goal and interventions related to activities. Young people with disabilities require a lifestyle plan and residents on mental health contracts require a specific relapse prevention plan/early warning signs to be documented.||PA Low||Reporting Complete||31/07/2018|
|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.||Due to evaluation and review processes not being undertaken within the expected timeframes, there was a lack of evidence that evaluations of residents’ care plans indicate the degree of achievement or response to the support and/or interventions and progress towards meeting the desired outcome.||Evaluations are undertaken within timeframes as required in the contract and indicate the level of progress with individualised goals or any identified changes for the person.||PA Moderate||Reporting Complete||31/07/2018|
|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).||The last documented quality review of restraint was undertaken in April 2017.||Provide evidence that quality reviews for restraint are undertaken to meet the requirements of the Standard.||PA Low||Reporting Complete||21/11/2019|
|A restraint register or equivalent process is established to record sufficient information to provide an auditable record of restraint use.||The restraint register sighted contained the name of the one resident currently using a restraint; however, there is insufficient information to provide an auditable record of ongoing reviews since 2017.||Provide evidence that restraint review dates are shown in the restraint register so it can be used as an auditable record.||PA Low||Reporting Complete||21/11/2019|
|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.||The medicine management system in place does not ensure the safe management of controlled drugs, nor does it ensure medications requiring refrigeration are stored within the correct temperature ranges. Mental health: Discussion with the clinical nurse manager revealed that it was not clear who was responsible for monitoring the side effects of this high risk medication. There was no protocol or system in place to identify who is responsible for metabolic monitoring, when to report side effects … (this text has been trimmed due to space limits).||Provide evidence the medication management system in place ensures safe storage and administration of medicines. Mental health: Develop a clozapine protocol to ensure the side effects of the medication are known and monitored and conditions (for example, infections, flu, high use of coffee or nicotine) that might impact on the clozapine levels are reported to the prescriber.||PA High||Reporting Complete||18/12/2019|
|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 restraint assessment form could be found for the resident with restraint in use.||Ensure that restraint assessments are documented prior to commencing restraint.||PA Low||Reporting Complete||18/12/2019|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Care plans do not always describe fully the required support to achieve the desired outcomes identified in the assessment process. Mental health: Records did not include early warning signs and relapse prevention plans.||Provide evidence the care plans describe fully the required support the resident requires to achieve the desired outcomes. Mental health: Record early warning signs and a relapse prevention plan.||PA Moderate||Reporting Complete||18/12/2019|
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: 05 April 2019
Audit type:Surveillance Audit
- Otatara Heights Residential Care - Apr 2019 (docx, 42.2 KB)
- Otatara Heights Residential Care - Apr 2019 (pdf, 163.9 KB)
Audit type:Certification Audit
- Otatara Heights Residential Care - Sep 2017 (docx, 53.64 KB)
- Otatara Heights Residential Care - Sep 2017 (pdf, 207.6 KB)
Audit type:Surveillance Audit
- Otatara Heights Residential Care - Apr 2016 (docx, 38.22 KB)
- Otatara Heights Residential Care - Apr 2016 (pdf, 129.13 KB)
Audit type:Certification Audit
- Otatara Heights Residential Care - Sep 2014 (docx, 126.27 KB)
- Otatara Heights Residential Care - Sep 2014 (pdf, 668.48 KB)
Audit type:Provisional Audit