Raeburn Lifecare

Profile & contact details

Premises details
Premises nameRaeburn Lifecare
Address 170 Burns Street Leamington Cambridge 3432
Total beds54
Service typesGeriatric, Medical, Dementia care, Rest home care
Certification/licence details
Certification/licence nameHeritage Lifecare Limited - Raeburn Lifecare
Current auditorThe DAA Group Limited
End date of current certificate/licence27 September 2019
Certification period12 months
Provider details
Provider nameHeritage Lifecare Limited
Street addressLevel 2 111 Johnsonville Road Johnsonville Wellington 6037
Post addressPO Box 13223 Johnsonville Wellington 6440

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: 01 August 2018

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Information of a private or personal nature is maintained in a secure manner that is not publicly accessible or observable.Not all consumer information was secured or stored appropriately. Ensure that all consumer information is easily accessible when required and protected from the risk of damage to documents and secure at all times. PA ModerateReporting Complete18/12/2018
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.Medication administration processes were not undertaken in accordance with the organisational policy and good practice in relation to checking and administration of medication. Provide evidence of safe medication management. PA ModerateReporting Complete18/12/2018
The facilitation of safe self-administration of medicines by consumers where appropriate.One resident self-administering their medicines did not have an up to date assessment to show competence to do so, nor had their medications stored in a locked box. Provide evidence that all residents who are self-administering medicines are meeting the facility’s policy requirements to do so safely. PA LowReporting Complete18/12/2018
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.Three residents’ long-term care plans and three interRAI assessments were not completed with the required timeframes. Ensure that all long-term care plans and interRAI assessments are completed within the required timeframes to meet contractual requirements. PA LowReporting Complete18/12/2018
Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.Three of six residents’ files reviewed in the dementia unit did not have a 24-hour behaviour clock to support challenging behaviour. Ensure that all residents in the dementia unit have a 24-hour ‘challenging behaviour clock’ to meet contractual requirements and support management of behaviour. PA LowReporting Complete18/12/2018
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.Two of 16 residents’ files reviewed did not have an evaluation completed to support the long-term care plan. Three of six files reviewed in the dementia unit did not have an overall review completed evaluating the resident’s challenging behaviours identified on the challenging behaviour monitoring forms. Ensure that all evaluations are completed to meet required timeframes and contractual requirements. PA LowReporting Complete18/12/2018
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).Two out of five residents for whom restraints were being used did not have their general practitioner’s sign off as part of the consent process, and one RN did not indicate their designation, as required to support safe restraint use. Provide evidence the doctor concerned has been involved in the decision process to provide restraint and consents to this practice for all residents concerned and the designation of staff involved is included. PA ModerateReporting Complete18/12/2018
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).Monitoring and quality review of restraint use was inadequate for three out of five residents, such that a lack of complete Oceania documentation was not noticed or rectified in a timely manner. Provide evidence the required restraint use documentation has been completed for all residents for whom restraints are being used. PA ModerateReporting Complete18/12/2018

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.

Audit reports

Audit date: 01 August 2018

Audit type:Provisional Audit

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