Pohlen Hospital Trust Board
Profile & contact details
|Premises name||Pohlen Hospital Trust Board|
|Address||56 Rawhiti Avenue Matamata 3400|
|Service types||Rest home care, Geriatric, Maternity, Surgical, Medical|
|Certification/licence name||Pohlen Hospital Trust Board|
|Current auditor||The DAA Group Limited|
|End date of current certificate/licence||14 April 2023|
|Certification period||48 months|
|Provider name||Pohlen Hospital Trust Board|
|Street address||56 Rawhiti Avenue Matamata 3400|
|Post address||PO Box 239 Matamata 3440|
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: 10 May 2021
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|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.||In total fourteen (14) medication records were reviewed across all services. Three of seven long term care residents’ medication records evidenced transcribing had taken place. When new medication charts are needing to be rewritten nurses are transcribing the information and asking the general practitioners to sign this at their next visit.||Ensure that medical staff prescribe on the medication charts when a new medication record is required.||PA Low||Reporting Complete||06/03/2020|
|Professional qualifications are validated, including evidence of registration and scope of practice for service providers.||Whilst there is a schedule to manage performance appraisals of staff, appraisals are not being completed as required.||Ensure performance appraisals are completed in a timely manner.||PA Low||Reporting Complete||06/03/2020|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Issues and corrective action plans are discussed at all meetings and forums. However, the documentation of the process is inconsistent and does not routinely provide the details of the corrective action, follow up process and closure of identified issue.||Ensure there is a consistent process to document corrective action planning, actions taken and the follow up or close out of corrective actions.||PA Low||Reporting Complete||06/03/2020|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||There is more than one location where staff training is recorded in the system. Collated data is not complete and does not provide a current training status for individual staff.||Ensure training records of staff are held in a systematic manner to enable the assessment of the current status of staff training at a glance.||PA Low||Reporting Complete||04/04/2022|
|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.||Ten of twenty long term care residents have not had there interRAI reassessments completed in the required timeframe since July 2020 and the majority of the care plans have not been updated.||Ensure the interRAI re-assessments are completed to ensure the care plans reflect the appropriate care required for each individual resident concerned.||PA Moderate||Reporting Complete||04/04/2022|
|Professional qualifications are validated, including evidence of registration and scope of practice for service providers.||Annual performance appraisals of staff are overdue by more than 50%.||Ensure a system is put in place to manage the delivery of annual performance appraisals.||PA Moderate||Reporting Complete||04/04/2022|
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.
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 reportsAudit date: 10 May 2021
Audit type:Surveillance Audit
- Pohlen Hospital Trust Board - May 2021 (docx, 35.67 KB)
- Pohlen Hospital Trust Board - May 2021 (pdf, 141.06 KB)
Audit type:Certification Audit
- Pohlen Hospital Trust Board - Feb 2019 (docx, 54.3 KB)
- Pohlen Hospital Trust Board - Feb 2019 (pdf, 210.48 KB)
Audit type:Surveillance Audit
- Pohlen Hospital Trust Board - Oct 2017 (docx, 32.23 KB)
- Pohlen Hospital Trust Board - Oct 2017 (pdf, 127.48 KB)
Audit type:Partial Provisional Audit
- Pohlen Hospital Trust Board - May 2016 (docx, 37.34 KB)
- Pohlen Hospital Trust Board - May 2016 (pdf, 127.27 KB)
Audit type:Certification Audit