Queen Rose Retirement Home

Profile & contact details

Premises details
Premises nameQueen Rose Retirement Home
Address 63 Queens Drive Saint Kilda Dunedin 9012
Total beds28
Service typesRest home care
Certification/licence details
Certification/licence nameQueen Rose Retirement Home Limited - Queen Rose Retirement Home
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence21 September 2019
Certification period36 months
Provider details
Provider nameQueen Rose Retirement Home Limited
Street address 63 Queens Drive St Kilda Dunedin 9012
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: 14 February 2018

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
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.The incident form following a head injury did not document neurological observations. Discussion with the registered nurse evidenced that neurological observations are not routinely undertaken post head injury. Ensure all head injuries have neurological observations completed. PA LowReporting Complete31/05/2017
The infection control team/personnel and/or committee shall comprise, or have access to, persons with the range of skills, expertise, and resources necessary to achieve the requirements of this Standard.The infection control coordinator has not updated infection control training in the past two years. Ensure the infection control coordinator maintains a current knowledge of infection control best practice. PA LowReporting Complete31/05/2017
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.Wound care documentation was incomplete for six out of eight wounds. Five out of the eight wounds had not been assessed and did not have treatment plans in place. Six out of the eight recent wounds did not have short-term care plans in place to document the interventions required. Two out of three wounds with treatment plans did not document the frequency of treatment. Five out of eight wounds did not have evidence of regular reviews. Ensure that wound assessment and management plans are fully documented and followed, and that all wounds have interventions documented in either a short-term care plan with regular documentation reviews or in a long-term care plan. PA LowReporting Complete31/05/2017
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.Two of the five files reviewed did not evidence pain assessments for residents requiring PRN pain medications. Ensure pain assessments are completed and reviewed for residents on PRN medication. PA LowReporting Complete31/05/2017
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.Expired medications are stored in an unlocked office for return to pharmacy. Opened eye drops did not identify the date the bottles were opened and eye drops in use on the trolley did not evidence the resident’s name. Ensure all expired medication is stored securely prior to return to pharmacy. Ensure eye drops are labelled with the residents name and the date the bottle was opened. PA LowReporting Complete31/05/2017
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.Three of five resident files did not evidence that care plan interventions provided sufficient detail to guide care staff. 1. One resident care plan was not updated to reflect sleep, wound management and intimacy interventions. 2. One resident care plan did not include non-medical pain management interventions. 3. One resident care plan did not include continence management interventions. Ensure that the interventions in the care plan reflect the resident’s current needs as identified through assessments and progress notes. PA LowReporting Complete13/07/2017
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.One of five resident files did not evidence that care plan interventions provided sufficient detail for management of diabetes to guide care staff. Ensure that the interventions in the care plan reflect the resident’s current needs as identified through assessments and progress notes. PA LowReporting Complete25/06/2018

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. 

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.

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