Palm Grove Rest Home
Profile & contact details
|Premises name||Palm Grove Rest Home|
|Address||8 Grove Road Narrow Neck Auckland 0624|
|Service types||Rest home care|
|Certification/licence name||Lifeline Agedcare Limited - Palm Grove Rest Home|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||01 August 2021|
|Certification period||36 months|
|Provider name||Lifeline Agecare Limited|
|Street address||8 Grove Road Davenport Auckland 0624|
|Post address||38 Vireya Court Goodwood Heights Manuka, Auckland 2105|
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: 16 March 2020
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|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service providers and managed to preclude the use of obsolete documents.||The document control system does not ensure outdated policies, documents and forms are removed from circulation and staff have not been informed of updated policies.||Ensure document control system is managed appropriately and staff are informed of new policies.||PA Low||Reporting Complete||28/01/2020|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||i) The current policy does not record appropriate skill mix for safe service delivery. ii) The prospective provider does not have a policy regarding staff skill mix, including contractual obligations and acuity of consumers within the service. iii) Staff rosters do not adhere to the ARRC contract requirements.||i) Ensure policy on safe service delivery is documented. ii) The prospective provider to provide a policy regarding staff skill mix, including contractual obligations and acuity of consumers within the service. iii) Provide evidence staff rosters adhere to ARRC contract requirements.||PA High||Reporting Complete||04/10/2019|
|All buildings, plant, and equipment comply with legislation.||i) Electrical equipment is not routinely checked for electrical safety and medical equipment has not been calibrated. ii) Hot water temperatures are outside of the recommended safe temperature range. iii) A preventative maintenance schedule is not implemented.||i) Ensure electrical checks are conducted and medical equipment is calibrated. ii) Ensure hot water temperatures are within a safe temperature range. iii) Ensure preventative maintenance of the building is conducted.||PA Moderate||Reporting Complete||30/10/2019|
|An appropriate 'call system' is available to summon assistance when required.||Not all resident areas have a call bell system installed to summon assistance.||Ensure all resident areas are provided with a call bell system to summon assistance.||PA Moderate||Reporting Complete||30/10/2019|
|There are adequate numbers of accessible toilets/showers/bathing facilities conveniently located and in close proximity to each service area to meet the needs of consumers. This excludes any toilets/showers/bathing facilities designated for service providers or visitor use.||Not all communal bathrooms have a system to indicate vacancy.||Ensure there is a system to indicate when communal bathrooms are in use.||PA Low||Reporting Complete||30/10/2019|
|Areas used by consumers and service providers are ventilated and heated appropriately.||i) One resident’s bedroom does not have an external window. ii) Heating is not provided in all residents’ rooms.||Ensure safe heating and ventilation is provided in all resident areas.||PA Low||Reporting Complete||30/10/2019|
|Service providers have access to designated areas for the safe and hygienic storage of cleaning/laundry equipment and chemicals.||Storage of chemicals was observed to be accessible to staff, residents and visitors.||Ensure safe storage areas are provided for chemicals accessible to staff only.||PA Low||Reporting Complete||30/10/2019|
|Consumers are provided with safe and accessible external areas that meet their needs.||The resident external areas are not all accessible with mobility aids, and has no safe seating or shade provided.||Ensure the external environment is safe, accessible and meets residents’ needs.||PA Low||Reporting Complete||30/10/2019|
|The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.||Events requiring essential notifications to authorities were not always reported to the appropriate authority.||Provide evidence statutory and regulatory obligations are completed when required.||PA Moderate||Reporting Complete||27/11/2019|
|The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.||i) Nursing progress notes are not completed in line with policy. ii) Activities attendance and activities progress notes are not maintained. iii) Handovers are not consistently conducted or ensure continuity of care.||i) Ensure nursing progress notes are completed in line with policy. ii) Ensure activities attendance and activities progress notes are maintained. iii) Ensure handovers are consistently conducted or ensure continuity of care.||PA Moderate||Reporting Complete||27/11/2019|
|Advance directives that are made available to service providers are acted on where valid.||Not all advanced directives comply with the requirements of legislation.||Provide evidence all resident advanced directives comply with legislation.||PA Moderate||Reporting Complete||06/01/2020|
|During a temporary absence a suitably qualified and/or experienced person performs the manager's role.||There is no formal document to record who performs the manager’s role during their temporary absence.||Provide evidence of a recorded policy identifying the person who is qualified and experienced to perform the manager’s role during their temporary absence.||PA Low||Reporting Complete||06/01/2020|
|Information of a private or personal nature is maintained in a secure manner that is not publicly accessible or observable.||Residents’ personal information was publicly visible at the facility.||Ensure residents’ personal information is not publicly visible.||PA Low||Reporting Complete||06/01/2020|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||Not all aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||Ensure all aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||PA Moderate||Reporting Complete||06/01/2020|
|Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include: (a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk; (b) A process that addresses/treats the risks associated with service provision is developed and im… (this text has been trimmed due to space limits).||i) The hazard register is not current or reviewed annually. ii) There were health and safety issues identified relating to the environment.||i) Ensure the hazard register is current. ii) Ensure the environment is maintained to ensure health and safety of staff, residents and visitors.||PA Moderate||Reporting Complete||06/01/2020|
|The appointment of appropriate service providers to safely meet the needs of consumers.||The human resource processes are not consistently followed.||Provide evidence the human resource processes are followed.||PA Low||Reporting Complete||06/01/2020|
|Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.||Fire drills are not conducted six monthly.||Ensure fire drills are completed six monthly.||PA Low||Reporting Complete||06/01/2020|
|Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.||The menu is not in line with recognised nutritional guidelines for aged residential care.||Ensure the menu is in line with recognised nutritional guidelines for aged residential care.||PA Moderate||Reporting Complete||06/01/2020|
|The methods, frequency, and materials used for cleaning and laundry processes are monitored for effectiveness.||Cleaning and laundry services require review and monitoring of the effectiveness of these services.||Provide evidence cleaning and laundry services are provided effectively.||PA Moderate||Reporting Complete||06/01/2020|
|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.||Neurological observations are not always conducted for unwitnessed falls.||Provide evidence neurological observations are completed for patient’s unwitnessed falls.||PA Moderate||Reporting Complete||06/01/2020|
|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.||Evaluations of care plans do not consistently document progress towards meeting the desired outcome or evidence resident and family/whānau (where applicable) involvement.||Provide evidence evaluations of care plans consistently document progress towards meeting the desired outcome and evidence resident and family/whānau (where applicable) involvement.||PA Moderate||Reporting Complete||06/01/2020|
|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 management of medicines did not consistently comply with legislation, protocols, and guidelines.||Ensure the management of medicines complies with legislation, protocols, and guidelines.||PA Moderate||Reporting Complete||06/01/2020|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Short-term care plans were not always in place for short-term problems.||Provide evidence short-term care plans were not always in place for short-term problems.||PA Moderate||Reporting Complete||06/01/2020|
|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.||Not all policies align with good practice and current legislative requirements.||Provide evidence all policies align with good practice and current legislative requirements.||PA Low||Reporting Complete||28/01/2020|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||i) Staff education does not include all relevant topics and the required staff education as per HDSS and the ARRC contract has not been completed. ii) Current competencies, including medication administration, were not able to be evidenced for all staff who required these.||i) Provide evidence staff education covers all required topics as per HDSS and the ARRC contract. ii) Provide evidence all staff have completed the relevant competencies such as medication administration.||PA Moderate||Reporting Complete||28/01/2020|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Corrective action plans are not always documented and implemented when required following internal audits, meetings and satisfaction surveys.||Provide evidence corrective action plans are documented and implemented when required following internal audits, meetings and satisfaction surveys.||PA Low||Reporting Complete||28/01/2020|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Quality data is not always collected, analysed and evaluated and the results communicated to all concerned.||Provide evidence the quality data is collected, analysed and evaluated and communicated to all concerned.||PA Low||Reporting Complete||28/01/2020|
|A process to measure achievement against the quality and risk management plan is implemented.||The process for measuring achievement against the quality and risk management plan is not consistently implemented.||Provide evidence of a process to measuring achievement against the quality and risk management plan.||PA Low||Reporting Complete||28/01/2020|
|Consumers have a right to full and frank information and open disclosure from service providers.||i) Not all adverse events reviewed evidenced family notifications. ii) Resident meeting minutes reviewed did not evidence residents’ ability to raise issues. iii) The admission information does not include all the requirements of HDSS and the ARRC contract. iv) The admission agreement does not include all the requirements of HDSS and the ARRC contract.||i) Provide evidence family are notified of adverse events. ii) Provide evidence residents have the ability to raise issues at resident meetings. iii) Ensure the admission information includes all the requirements of HDSS and the ARRC contract. iv) Ensure the admission agreement includes all the requirements of HDSS and the ARRC contract.||PA Moderate||Reporting Complete||28/01/2020|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||The activities programme is not fully implemented to develop and maintain residents’ strengths, interests and skills that are meaningful to the residents.||Provide evidence an activities programme is implemented that promotes residents’ strengths, interests and skills that are meaningful to the residents.||PA Moderate||Reporting Complete||02/03/2020|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||Resident files reviewed did not evidence services and/or interventions are consistent with, and contribute to, meeting residents’ assessed needs and desired outcomes.||Ensure residents receive services and interventions which are consistent with, and contribute to, meeting their assessed needs and desired outcomes.||PA High||Reporting Complete||18/03/2020|
|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.||i) InterRAI assessments and long-term care plans were not consistently completed within three weeks of admission. ii) InterRAI reassessments and long-term care plans were not evaluated six monthly or when the residents condition changed. iii) Activities assessments and care plans were not completed within the required timeframes.||Provide evidence the required residents’ assessments and care plans are consistently completed within the required timeframes.||PA Moderate||Reporting Complete||11/05/2020|
|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.||Resident needs are not always documented via the assessment process and do not inform care plans.||Provide evidence resident needs are documented via the assessment process and inform care plans.||PA Moderate||Reporting Complete||11/05/2020|
|Areas used by consumers and service providers are ventilated and heated appropriately.||There is one resident room without an external window.||Ensure all resident rooms have one external window allowing for natural light to enter the room.||PA Moderate||In Progress|
|The methods, frequency, and materials used for cleaning and laundry processes are monitored for effectiveness.||(i) There were no cleaning schedules in place to monitor the frequency and completion of cleaning duties. (ii) Internal cleaning audits are only completed annually.||(i) Ensure cleaning duties are scheduled and completed. (ii) Audit cleaning services more frequently.||PA Moderate||In Progress|
|Service providers have access to designated areas for the safe and hygienic storage of cleaning/laundry equipment and chemicals.||Cleaning chemicals were observed to be accessible to residents and visitors.||Ensure safe storage areas are provided for chemicals.||PA Moderate||In Progress|
|Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include: (a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk; (b) A process that addresses/treats the risks associated with service provision is developed and im… (this text has been trimmed due to space limits).||The hazard register is not current and has not been reviewed on due date.||Ensure the hazard register is current and reviewed annually.||PA Moderate||In Progress|
|All consumer-designated rooms (personal/living areas) have at least one external window of normal proportions to provide natural light.||One resident’s room only has an internal window||Ensure all resident rooms have external windows||PA Low||In Progress|
|All buildings, plant, and equipment comply with legislation.||(i) Resident related electrical equipment in bedrooms have not been routinely checked for electrical safety including oil filled heaters. (ii) A preventative maintenance schedule is not implemented to ensure the safety of residents and eliminate hazards including lifting floorboards outside the doorway to two communal toilets, one external exit door does not close properly and some external corners of the building are sharp and hazardous to residents.||(i) Ensure electrical checks are conducted for resident equipment. (ii) Ensure preventative and planned maintenance is completed.||PA Moderate||In Progress|
|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.||(i) There was no medical information obtained for the respite care resident and a behaviour assessment had not been completed as the resident was a wandering risk. (ii) There were no pain assessments completed for; (a) one resident admitted on restricted medication for pain management, and (b) one resident with a new pain requiring GP review and analgesia. (iii) Admission observations including weight had not been completed for three residents (two long-term and one respite care). … (this text has been trimmed due to space limits).||(i) Ensure initial assessments include available medical information. (ii) Ensure risk assessments and pain assessments are completed for known risks/problems. (iii) Ensure observations including weight are completed on admission.||PA Moderate||In Progress|
|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.||Neurological observations had not been completed as per protocol for four of four unwitnessed falls reviewed.||Ensure neurological observations are completed for unwitnessed falls.||PA Moderate||In Progress|
|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.||(i) One long-term care plans was not developed within three weeks of admission. (ii) One resident file reviewed did not have the interRAI assessment completed six monthly and the long-term care plan, including the activity plan had not been evaluated six monthly.||(i) – (ii) Ensure long-term care plans, six monthly interRAI assessments and long-term care plan evaluations are completed within the required timeframes.||PA Moderate||In Progress|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Care plan interventions were not updated in the LTCP or a STCP developed for; (i) a resident with 3kg weight loss since admission, (ii) a resident with new pain as per GP notes and progress notes. The same resident did not have the risks of Warfarin documented in the care plan.||(i) Care plan interventions are updated in the LTCP or a STCP developed; and (ii) Ensure medication risks are documented in care plans.||PA Moderate||In Progress|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||The results/outcomes and corrective actions of internal audits are not communicated at staff meetings.||Ensure the outcomes and corrective actions of internal audits are communicated to all staff.||PA Moderate||In Progress|
|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.||(i) The medication keys were being kept in a drawer in the dining room accessible to all staff. (ii) There was no medication chart or pharmacy prescription for the administration of medications for the respite care resident.||(i) Ensure the medication keys are kept on the person responsible for the administration of medications. (ii) Ensure there is a medication chart or current pharmacy prescription for the administration of medications for respite care residents.||PA Moderate||Reporting Complete||30/06/2020|
|The facilitation of safe self-administration of medicines by consumers where appropriate.||The self-medication competency had not been reviewed since October 2019.||Ensure self-medication competencies are reviewed three monthly.||PA Low||Reporting Complete||30/06/2020|
|Consumers are provided with safe and accessible external areas that meet their needs.||There were two wooden outdoor seats that were unstable and unsafe to use.||Ensure outdoor seating is safe to use.||PA Moderate||Reporting Complete||30/06/2020|
|An appropriate 'call system' is available to summon assistance when required.||The call bell system is not integrated therefore calls are not responded to in a timely manner.||Ensure there is an effective call bell system in place to summon assistance.||PA Moderate||Reporting Complete||30/06/2020|
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: 16 March 2020
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Provisional Audit