Raglan Trust Hospital and Rest Home
Profile & contact details
|Premises name||Raglan Trust Hospital and Rest Home|
|Address||29 Manukau Road Raglan 3225|
|Service types||Rest home care, Geriatric, Medical, Sensory|
|Certification/licence name||Ki-Chi Service Supplies Company Limited|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||18 April 2018|
|Certification period||36 months|
|Provider name||Ki-Chi Service Supplies Company Limited|
|Street address||29 Manukau Road Raglan 3225|
|Post address||PO Box 19628 Avondale Auckland 1746|
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: 12 June 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Results of surveillance, conclusions, and specific recommendations to assist in achieving infection reduction and prevention outcomes are acted upon, evaluated, and reported to relevant personnel and management in a timely manner.||i) The information noted on the separate infection logs for February and April was not consistent, and the analysis and benchmarking of the results was therefore based on inaccurate data ii) Where opportunities for improvements were noted, corrective action plans were not documented, implemented or communicated to staff.||i) Ensure that the information noted on the infection logs is accurate, and the analysis and benchmarking of infections is based on accurate data. ii) Where opportunities for improvements are noted, ensure corrective action plans are documented, implemented and communicated to staff.||PA Moderate||Reporting Complete||12/12/2017|
|The service is able to demonstrate that written consent is obtained where required.||Four of five files sampled (two rest home and to hospital) had no evidence that the general consents had been signed by the resident family or EPOA (as appropriate.)||Ensure that general consents are fully completed and appropriately signed.||PA Low||Reporting Complete||20/09/2017|
|Advance directives that are made available to service providers are acted on where valid.||One of five files sampled (hospital), where the resident was deemed to be competent, did not evidence that the advanced directive requesting no resuscitation had been signed by the resident.||Ensure that all advanced directives, are fully completed and appropriately signed.||PA Low||Reporting Complete||20/09/2017|
|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.||Three of three activity care plans (two rest home, one hospital) that were due for review had been reviewed 6 monthly, but not at the same time as the review of the long-term care plan or against the stated goals.||Ensure that all activity plans are reviewed in conjunction with a review of the long-term care plan and the activity plan is reviewed against the resident’s stated goals.||PA Low||Reporting Complete||27/09/2017|
|The appointment of appropriate service providers to safely meet the needs of consumers.||Completed reference checks were not available for sighting in four of the five staff files audited.||Ensure reference checks are undertaken for all new staff.||PA Low||Reporting Complete||27/09/2017|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||Two verbal and one written complaint received were not included in the complaints register. There was no documented evidence that these complaints had been managed in a timely and effective manner.||Ensure all complaints, verbal and written, are documented in the complaints register and reflect evidence of responding to each complaint in a timely manner.||PA Low||Reporting Complete||25/10/2017|
|The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.||The 2015 – 2017 business/quality action plan has not been implemented or reviewed.||Ensure the 2015 – 2017 business/quality plan is regularly reviewed with evidence of implementation.||PA Moderate||Reporting Complete||16/11/2017|
|Each episode of restraint is documented in sufficient detail to provide an accurate account of the indication for use, intervention, duration, its outcome, and shall include but is not limited to: (a) Details of the reasons for initiating the restraint, including the desired outcome; (b) Details of alternative interventions (including de-escalation techniques where applicable) that were attempted or considered prior to the use of restraint; (c) Details of any advocacy/support offered, provided o… (this text has been trimmed due to space limits).||i) Two of four residents (hospital) using a restraint (fall out chair and a lazy boy chair) did not have a restraint care plan documented. ii) Three of four residents (hospital) using a restraint did not have the required monitoring consistently documented.||i) Ensure that all residents using restraint have a care plan documented to manage the identified risks associated with the use of the restraint. ii) Ensure that monitoring of residents using a restraint is consistently documented and complies with the organisational requirements and care plan instructions.||PA Moderate||Reporting Complete||17/11/2017|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||i) The clinical indicator data is collected. Results posted in the staff room were over two months behind schedule (March 2017). ii) Clinical indicator data is not analysed or evaluated.||Ensure that all clinical indicator data is presented to staff in a timely manner and that the data is analysed and evaluated to identify service improvements.||PA Moderate||Reporting Complete||17/11/2017|
|Key components of service delivery shall be explicitly linked to the quality management system.||Staff meetings are not being held as per the meeting schedule. The facility manager reported that this is due to poor attendance at meetings. Where staff meetings have occurred, there is no evidence that quality data, trends, and corrective actions are discussed with staff.||Ensure that meetings are held on a regular basis to communicate all relevant aspects of the quality management system. Ensure that meeting minutes are made available to staff who are unable to attend.||PA Low||Reporting Complete||17/11/2017|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||Reviews of eight staff training records indicated that only two of the eight staff had completed a minimum of eight hours of mandatory training as per the Aged Residential Care (ARC) contract. Attendance at in-service training is consistently below 50% except for one in-service (fire training).||Ensure that the annual education planner is fully implemented and that education and training is provided to meet the requirements of the ARRC contract.||PA Low||Reporting Complete||17/11/2017|
|The organisation has a quality and risk management system which is understood and implemented by service providers.||The documented quality and risk management plan/programme is not fully implemented.||Ensure that all aspects of the quality and risk management system are implemented.||PA Moderate||Reporting Complete||20/11/2017|
|A process to measure achievement against the quality and risk management plan is implemented.||The annual monitoring schedule has not been fully implemented. The facility manager reported that she is working on this and hopes to fully implement the Cavell audit schedule by 2018.||Ensure that the monitoring schedule is fully implemented.||PA Moderate||Reporting Complete||28/11/2017|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||i) No corrective action plans were sighted or remedial actions evidenced where clinical indicator data identified areas requiring improvement. The clinical indicator data that was above an acceptable benchmark included residents’ falls and bruising. ii) The resident satisfaction survey completed in December 2016 identified that residents were unhappy with the meals being served. No corrective actions had been put in place to address this. The facility manager reported that she planned to r… (this text has been trimmed due to space limits).||Ensure that corrective actions are documented with evidence of their implementation where there are areas identified for improvements.||PA Moderate||Reporting Complete||28/11/2017|
|The facilitation of safe self-administration of medicines by consumers where appropriate.||i) Two of two rest home residents who were self-medicating, did not evidence a three-monthly review of their competence to self-medicate. ii) Two of two rest home residents self-medicating did not have evidence of a review by the registered nurse to check the medication was being administered as prescribed, on each shift. iii) One of two rest home residents did not have the medication being self-administered, stored securely.||i) Ensure that all residents who are self-administering medication, have the capacity to self-medicate reviewed at least three monthly or as required, as outlined in the organisational policy and Medicines Care Guides for Residential Aged Care 2011. ii) Ensure that all residents who are self-medicating have a check by a registered nurse that resident has taken the medication as prescribed on each shift. iii) Ensure that all medication being self-administered is secured in a locked cabinet/dra… (this text has been trimmed due to space limits).||PA Moderate||Reporting Complete||28/11/2017|
|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.||i) Six of ten medication charts reviewed (three rest home, three hospital) had medications, listed and then bracketed and group signed and dated. ii) Two of ten medication charts reviewed (hospital) did not have photo identification.||i) Ensure that medication charting complies with all organisational polices, and legal and contractual requirements. ii) Ensure that all medication charts have photo identification.||PA Moderate||Reporting Complete||28/11/2017|
|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) Two of five files sampled (hospital - including the tracer) did not have the initial assessment and the initial care plan documented within 48 hours of admission. ii) Two of four files sampled (hospital) did not have the long-term care plan documented within 21 days of admission. iii) Three of three files sampled (two rest home and one hospital) that required a review of the interRAI assessment and the long-term care plan had an interRAI re-assessment and long-term care plan review compl… (this text has been trimmed due to space limits).||i-iii) Ensure that all assessments, care plans and reviews are completed within the required timeframes.||PA Moderate||Reporting Complete||28/11/2017|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||i) Five of five care plans sampled did not have interventions documented for all current assessed needs. ii) Four of five files sampled (two rest home and two hospital) where interventions were documented, lacked sufficient detail to guide the care staff in the management of behaviours, short-term memory loss, night wandering, and the specific monitoring required for signs of infection and delirium. iii) Three of five files sampled (two rest home one hospital) did not have short-term care pla… (this text has been trimmed due to space limits).||i-iii) Ensure that care plans are documented for all identified care needs and in sufficient detail to guide the care staff. iv) Ensure that each wound has an individual wound care plan documented. v) Ensure interventions documented by allied health care staff are transferred to the care plan.||PA Moderate||Reporting Complete||28/11/2017|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Two of five staff files reviewed did not evidence completion of the orientation programme.||Ensure that all staff complete the organisation’s orientation requirements.||PA Low||Reporting Complete||04/12/2017|
|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.||i) Six of ten medication files reviewed (four rest home, two hospital) did not evidence at least a three monthly review of the medication prescribed by the GP. ii) Two of ten medication charts reviewed (hospital) could not evidence that all regular medication was being administered as required.||i) Ensure that all residents’ medication is reviewed at least 3 monthly. ii) Ensure all medication is administered as prescribed.||PA Moderate||Reporting Complete||04/12/2017|
|Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.||End cooked food temperatures are not consistently being recorded.||Ensure that food temperatures are taken and food is maintained and served to the residents at the correct temperature.||PA Low||Reporting Complete||12/12/2017|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||i) The kitchen cleaning schedule was not fully implemented and the under-bench areas in the kitchen, pantry shelves and the fridge in the residents dining room were dirty. ii) There were areas of exposed and swollen bare timbers in the pantries and under the bench in the dishwashing area. iii) There were no hats available for staff to wear in the kitchen or whilst preparing food. iv) Not all food stored in the food fridges was labelled and dated and where the food was labelled the use by date … (this text has been trimmed due to space limits).||i) Ensure that the kitchen cleaning schedule is fully implemented and all areas of the kitchen and food storage areas are clean. ii) Ensure that all reactive maintenance required in the kitchen is completed. iii) Ensure that there are hats available for staff to wear in the kitchen or whilst preparing food. iv) Ensure that all food stored in the resident food fridges is labelled and dated and all sections of the label are completed.||PA Moderate||Reporting Complete||12/12/2017|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||i) Two of five care plans reviewed (hospital tracer and one rest home) did not have all interventions is use documented in the care plan including the use of a pressure relieving cushion and use of medication for breathlessness, ii) Four of four care plans reviewed (two hospital and two rest home) did not have the required monitoring consistently documented as required by the long-term care plan for the completion of physiotherapy and one hospital resident with a PEG tube, did not have the … (this text has been trimmed due to space limits).||i) Ensure that all interventions in use are documented. ii) Ensure that the required monitoring occurs and is documented. iii) Ensure all wounds are redressed in the required timeframes.||PA Moderate||Reporting Complete||12/12/2017|
|Where progress is different from expected, the service responds by initiating changes to the service delivery plan.||i) Two of five long-term care plans (one rest home and one hospital) were not updated following a change in health condition for; a) one hospital resident following a change in health condition and a meeting with the family regarding the use of hip protectors, access to the garden, and referral to a continence nurse, b) one rest home resident following a change from long-term care to palliative care, an increase from minimal assistance to full assistance with all ADLs, a change in falls risk … (this text has been trimmed due to space limits).||i) Ensure that care plans are updated following a change in health condition. ii) Ensure that wound care plans are evaluated as required, and the management of the wound is transferred to the long-term care plan after 21 days.||PA Low||Reporting Complete||12/12/2017|
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: 12 June 2017
Audit type:Surveillance Audit
- Raglan Trust Hospital and Rest Home - Jun 2017 (docx, 43 KB)
- Raglan Trust Hospital and Rest Home - Jun 2017 (pdf, 171.98 KB)
Audit type:Surveillance Audit
- Raglan Trust Hospital and Rest Home - Aug 2016 (docx, 41.99 KB)
- Raglan Trust Hospital and Rest Home - Aug 2016 (pdf, 165.42 KB)
Audit type:Certification Audit
- Raglan Trust Hospital and Rest Home - Feb 2015 (docx, 43.86 KB)
- Raglan Trust Hospital and Rest Home - Feb 2015 (pdf, 171.13 KB)
Audit type:Partial Provisional Audit
- Raglan Trust Hospital and Rest Home - Feb 2014 (docx, 75.54 KB)
- Raglan Trust Hospital and Rest Home - Feb 2014 (pdf, 225.1 KB)
Audit type:Surveillance Audit
- Raglan Trust Hospital and Rest Home - Nov 2013 (docx, 119.85 KB)
- Raglan Trust Hospital and Rest Home - Nov 2013 (pdf, 404.66 KB)
Audit type:Certification Audit
Audit type:Surveillance Audit