Rose Lodge Rest Home
Profile & contact details
|Premises name||Rose Lodge Rest Home|
|Address||2 Liverpool Street Epsom Auckland 1023|
|Service types||Rest home care|
|Certification/licence name||Graceful Home Limited - Rose Lodge Rest Home|
|Current auditor||HealthShare Limited|
|End date of current certificate/licence||14 February 2019|
|Certification period||24 months|
|Provider name||Graceful Home Limited|
|Street address||2 Liverpool Street Epsom Auckland 1023|
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: 20 November 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|The appointment of appropriate service providers to safely meet the needs of consumers.||The service was using a volunteer to provide care to residents. There was no formal agreement in place clarifying the volunteer arrangements. There was no evidence of police vetting, reference checking, orientation or health and safety training.||Ensure the volunteer relationship is documented, meets legislative guidelines and protects resident safety.||PA Moderate||Reporting Complete||26/04/2017|
|Entry criteria, assessment, and entry screening processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies.||One privately paying resident does not have a needs assessment completed.||Ensure that each resident has a needs assessment completed prior to entry to the service.||PA Moderate||Reporting Complete||26/04/2017|
|All buildings, plant, and equipment comply with legislation.||Seven maintenance issues were identified as part of the audit. The maintenance issues identified were as follows: (1) there was no evidence that electrical equipment which was non-fixed wired had been subject to testing and tagging by an electrician; (2) the calibration and re-testing date for the thermometer and the sphygmomanometer had expired and there was no evidence that the weighing scales had been calibrated or purchased recently; (3) the floor tiles in the northern bathroom in the area … (this text has been trimmed due to space limits).||Ensure the reactive maintenance programme maintains the internal and external amenities, fixtures and fittings in an appropriate condition to meet both consumer and staff needs, and that users of the buildings are not at risk from secondary tobacco smoke.||PA Low||Reporting Complete||26/04/2017|
|Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.||The supply of emergency water as identified by the managing director was sighted. This supply of water was stored outside the building in an unsecured container the size of a 40 litre rubbish bin. The water stored on the day was contaminated by insects, looked dirty, and the amount of water was insufficient to meet the hydration and cleanliness needs of residents and staff for at least three days in an emergency.||Ensure the facility carries sufficient amounts of potable and non-potable water so that in an emergency, where the town water supply is unable to be accessed, there is sufficient water stored on site to safely meet the needs of all residents and staff on duty for at least a minimum of three days.||PA Moderate||Reporting Complete||26/04/2017|
|Where required by legislation there is an approved evacuation plan.||An approved evacuation plan was unable to be sighted on the day of audit although reference to such a plan exists in previous audit documentation. There was no documented record of the recent fire evacuation drill that included a record of the date, time and the minutes taken for staff and residents to fully evacuate the building.||Ensure a copy of the approved evacuation plan is obtained and implemented including the owner’s responsibilities regarding the conducting of trial evacuations.||PA Low||Reporting Complete||26/04/2017|
|An appropriate 'call system' is available to summon assistance when required.||There is no call bell system installed in the external bedroom with ensuite, or the dining room and lounge in the main building.||Ensure there is an appropriate call bell system installed that enables all residents to be able to summon assistance from staff when required.||PA Moderate||Reporting Complete||26/04/2017|
|Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.||A review of the menu has not been completed since April 2014.||Ensure that the menu is reviewed in line with residents’ needs.||PA Moderate||Reporting Complete||11/12/2017|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||One cook does not have food safety training.||Ensure that all cooks have food safety training.||PA Low||Reporting Complete||11/12/2017|
|Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.||A review of the menu has not been completed since April 2014. The improvement identified at the previous audit continues to be required.||Ensure that the menu is reviewed in line with residents’ needs. The risk rating remains as moderate however the time frame for completion of the corrective action has been reduced.||PA Moderate||In Progress|
|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.||The interRAI assessment is not completed six monthly in line with the review of the care plan.||Ensure that an interRAI assessment is completed six monthly in line with the review of the care plan.||PA Low||Reporting Complete||24/01/2018|
|Advance directives that are made available to service providers are acted on where valid.||The review of the advance directive does not clearly document that the resident has been engaged in the discussion around review of the advance directive.||Review documentation of annual review of advance directives to ensure that there is clarity around input from the resident into the decision.||PA Negligible||Reporting Complete||24/01/2018|
|Advance directives that are made available to service providers are acted on where valid.||The review of the advance directive does not clearly document that the resident has been engaged in the discussion around review of the advance directive. The partial attainment identified at the previous audit remains. Two of the five resident files reviewed do not have a signed advance directive. This is a new partial attainment.||Review documentation of annual review of advance directives to ensure that only the resident deemed competent signs for an advance directive. The risk rating has been raised to low from negligible at the previous audit. Ensure that each resident can sign an advance directive.||PA Low||Reporting Complete||14/03/2018|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||The complaints register did not document a record of any complaints received in 2017.||Update the complaints register for 2017.||PA Negligible||Reporting Complete||14/03/2018|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Data has not been graphed or trends reviewed since February 2017. This is a new improvement required.||Reinstate review of trends as planned with evidence of service improvement when necessary.||PA Low||Reporting Complete||14/03/2018|
|Professional qualifications are validated, including evidence of registration and scope of practice for service providers.||The annual practicing certificate is not current for the podiatrist and pharmacists. This is a new improvement required.||Ensure that a record of annual practicing certificates is retained by the service for visiting health professionals.||PA Low||Reporting Complete||14/03/2018|
|The appointment of appropriate service providers to safely meet the needs of consumers.||Two of the staff files reviewed do not have a signed contract in place. This is a new improvement required.||Ensure that each staff member has a signed contract on file.||PA Moderate||Reporting Complete||14/03/2018|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||Two staff files do not have a current annual performance appraisal on file. This is a new improvement required.||Ensure that all staff have an annual performance appraisal.||PA Low||Reporting Complete||14/03/2018|
|Entry criteria, assessment, and entry screening processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies.||Two resident files reviewed did not include an admission agreement. This is a new improvement required.||Ensure that each resident sign an admission agreement on entry to the service.||PA Low||Reporting Complete||14/03/2018|
|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.||New residents who have entered the service since the last audit do not have an initial interRAI assessment completed within three weeks of entry. The interRAI assessment is not completed six monthly in line with the review of the care plan. The improvements required at the previous audit remain.||Ensure that each new resident has an initial interRAI assessment completed within three weeks of entry to the service. Ensure that an interRAI assessment is completed six monthly in line with the review of the care plan. The risk rating has been raised to moderate.||PA Moderate||Reporting Complete||14/03/2018|
|All buildings, plant, and equipment comply with legislation.||A current BWOF is not displayed.||Ensure that there is a current BWOF displayed.||PA Moderate||Reporting Complete||14/03/2018|
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: 20 November 2017
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit