Profile & contact details
|Premises name||Radius Hawthorne|
|Address||10 St Winifreds Place Bryndwr Christchurch 8052|
|Service types||Rest home care, Physical, Psychogeriatric, Geriatric, Medical|
|Certification/licence name||Radius Residential Care Limited - Radius Hawthorne|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||10 September 2021|
|Certification period||Other months|
|Provider name||Radius Residential Care Limited|
|Street address||12 Viaduct Harbour Avenue Auckland Central Auckland 1010|
|Post address||PO Box 450 Auckland 1140|
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: 30 January 2019
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||Over nine weeks of the roster sampled there were two weekends where there was an enrolled nurse but no registered nurse on duty in the hospital on morning shift.||Ensure there is a registered nurse on duty in the hospital wings at all times.||PA Low||Reporting Complete||07/11/2017|
|Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.||Three of sixteen medication files sampled did not have allergies, or allergy status documented.||Ensure all medication charts have the allergy status documented.||PA Low||Reporting Complete||07/11/2017|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||(i) There was no documented evidence of accidents and incidents or infections having been analysed for trends. (ii) Meeting minutes (quality, registered staff and staff) did not include discussion around trends (including but not limited to pressure injuries, incidents and infections), corrective action plans or complaints.||(i & ii) Ensure that quality data is analysed for trends and that staff are informed of the outcomes of quality activities including trend analysis.||PA Moderate||Reporting Complete||14/02/2018|
|Service providers responsible for medicine management are competent to perform the function for each stage they manage.||Two of three RN files sampled did not have a medication competency completed when they commenced employment.||Ensure all staff who administer medications have a documented competency on file.||PA Low||Reporting Complete||14/02/2018|
|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.||Four of eight files sampled (two hospital and two psychogeriatric) did not have a long-term care plan completed within three weeks of admission. Two of four files sampled under the ARHSS contract did not have contractual timeframes around interRAI met. One hospital file sampled had a period of 11 months between evaluations.||Ensure all assessment, care plan and evaluation requirements are completed within contractual timeframes.||PA Low||Reporting Complete||14/02/2018|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||(i) There has been no staff training around wound management or cultural safety in the past two years. (ii) Staff attendance at some required trainings was low. (iii) Eleven healthcare assistants who have worked in the psychogeriatric units for longer than one year have not yet completed the required dementia standards.||(i) Ensure that all required trainings are provided. (ii) Continue to ensure that sufficient staff attend education sessions. (iii) Ensure that all staff who have worked in the psychogeriatric units for longer than one year have completed the required dementia standards.||PA Low||Reporting Complete||29/05/2018|
|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.||Five of eight care plans sampled (two psychogeriatric including one on a long-term support chronic health condition contract and three hospital including one on an ACC contract) did not document progress towards goals.||Ensure evaluations document progress toward desired outcomes.||PA Low||Reporting Complete||29/05/2018|
|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)Two resident’s medication charts documented short-term antibiotics (total of eight entries) prescribed for a week at a time (which are no longer given) that have not been discontinued on the medicine chart by the GP. ii) The medication trolley and keys were found unattended in the nurse’s station with the door open.||i)Ensure that medication charts are reviewed, and short-term medications have been discontinued by the GP on completion of the course. ii) Always ensure the medication trolley is locked when unattended, and the keys are in possession of the RN at all times.||PA Moderate||Reporting Complete||29/05/2019|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||In two psychogeriatric files reviewed (one from each unit), there were no possible triggers either environmental or sensory in the care plans or behaviour charts reviewed.||Ensure triggers are identified and included in the care plans and the behaviour charts to alert staff to avoid potential episodes of challenging behaviours.||PA Low||Reporting Complete||24/07/2019|
|The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.||(i)Progress notes of one hospital file identified no RN progress notes documented for four days. (ii)RN progress note in one PG resident file does not describe the details of the residents “unsettled behaviour” or diversion/ de-escalation techniques used prior to administering antipsychotic drugs. There are no details of the resident’s movements and mood throughout the day.||Ensure all registered nurses notes are documented on time and provide details of resident’s condition and episodes of challenging behaviours.||PA Low||Reporting Complete||24/07/2019|
|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.||One rest home file, and one psychogeriatric file sampled did not have an interRAI assessment or long-term care plan completed within 21 days of admission||Ensure all assessments and care plans are completed within 21 days of admission.||PA Moderate||Reporting Complete||24/07/2019|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||The fridge/ freezer temperatures have not been consistently recorded in the Sumner wing.||Ensure the temperature of the fridge/ freezer is checked and recorded on a daily basis.||PA Low||Reporting Complete||24/07/2019|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||Staff attendance at some required trainings is less than 50% (continence, skin care & PI prevention, pain management, H & S and emergency training, dementia, delirium and challenging behaviour).||Ensure staff attend mandatory training sessions.||PA Moderate||Reporting Complete||24/07/2019|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Survey results for 2018 have not been analysed. Results have not been evaluated or shared with staff, residents or families.||Ensure survey results are analysed and results communicated to staff and where appropriate with consumers||PA Moderate||Reporting Complete||24/07/2019|
|The service is able to demonstrate that written consent is obtained where required.||Six psychogeriatric files were reviewed (four for EPOA only). Four files did not have an activated EPOA on file, however one of these files did have documentation of assessment and court order for guardianship.||Ensure all EPOAs have been activated and are on file for all dementia residents on admission.||PA Low||Reporting Complete||03/09/2019|
|The appointment of appropriate service providers to safely meet the needs of consumers.||(i)Two of four long-term staff who have been employed longer than eighteen months did not evidence appraisals had been completed. (ii) Three of seven staff who have been employed over six months have not had a three-month appraisal completed.||(i)Ensure all staff have annual reviews completed. (ii) Ensure all staff have three-month appraisals completed||PA Low||Reporting Complete||08/10/2019|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Two registered nurses that have been at the facility for over six months do not have completed orientations on file.||Ensure all staff have completed orientations on file.||PA Low||Reporting Complete||08/10/2019|
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: 30 January 2019
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit