Profile & contact details
|Premises name||Roseneath Lifecare|
|Address||227 High Street South Carterton 5713|
|Service types||Dementia care, Rest home care, Geriatric, Medical|
|Certification/licence name||Heritage Lifecare Limited - Roseneath Lifecare|
|Current auditor||The DAA Group Limited|
|End date of current certificate/licence||06 August 2023|
|Certification period||24 months|
|Provider name||Heritage Lifecare Limited|
|Street address||Level 2 111 Johnsonville Road Johnsonville Wellington 6037|
|Post address||PO 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: 02 June 2021
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.||The maintenance manager is responsible for water temperature monitoring on a monthly basis. Records evidence that these are completed but water temperature variances were not being reported to the CHM and action taken as a result.||To ensure the water temperatures monitoring occurs monthly and that any variances are reported to management in a timely manner and that action is taken when necessary to ensure safety for residents.||PA Moderate||In Progress|
|There is a document control system to manage the policies and procedures. This system shall ensure documents are approved, up to date, available to service providers and managed to preclude the use of obsolete documents.||The organisation has a document control system to manage policies and procedures. This is the responsibility of the support office quality management team. The current system is not functioning adequately to ensure the CHM has updated policies and procedures that have been approved, reviewed, dated and are up-to-date. Policies and procedures have not been reviewed and brought to the attention of staff. Current policies are out of date - some dated 2014 and 2015.||To ensure there is a document control system that is effective to manage the policies and procedures. The system should ensure documents are approved, up to date and available to service providers and managed to prelude the use of obsolete documents.||PA Moderate||Reporting Complete||08/10/2021|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Quality data has been inconsistently gathered since the previous audit and when information is analysed. Evaluated or in particular when a corrective action is required for continuous improvement, this is not always actioned, followed through, signed or dated and identified risk is not acknowledged. Minimal strategies are in place to obtain feedback from staff, families and/or residents for continuous quality improvement purposes. The last annual survey was dated September 2019.||To ensure the process is followed for measuring achievements across the services provided. Quality improvement data is collected is to be consistently analysed and evaluated for achievement against the quality and risk management plan implemented.||PA Moderate||Reporting Complete||08/10/2021|
|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.||In the last six months there have been 172 incidents reported by staff and 31 incidents have been actioned/addressed and/or closed out effectively in the incident register reviewed. 140 incidents were reported prior to April 2021.||All incidents are to be followed through in order to identify and manage any risks and/or opportunities to improve service delivery.||PA Moderate||Reporting Complete||08/10/2021|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||There is no documented and implemented process which determines service provider level and skill mixes in order to provide safe service delivery. When the rosters were reviewed there are two times in the 24 hour period when there is only one health care assistant in the evening both in the rest home/hospital and secure dementia care service. Due to the layout and design of the services this is not adequately covered to meet the needs of the residents. In addition to these findings, staff with fi… (this text has been trimmed due to space limits).||To ensure there is an appropriate policy with a rationale for determining staffing levels and skill mixes in order to provide safe service delivery. There has to be adequate staff on duty to cover the respective services as required on all shifts and a staff member with appropriate first aid skills is to be rostered on all shifts in all service areas.||PA Moderate||Reporting Complete||08/10/2021|
|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.||Full and complete assessments are not being completed as required within 24 hours of admission for all residents to inform the long term care plan. Eight interRAI reassessments and care plan evaluations are outstanding dating to March 2021.||All interRAI and care plan assessments/reassessments are current and completed within the required time frames.||PA Moderate||Reporting Complete||08/10/2021|
|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.||Evaluations across many areas of service intervention such as interim care plans, short term care plans, monitoring of weights, monthly recordings, neurological recordings post falls, wound evaluations and effectiveness of pro ne rata medications are not being consistently evaluated and progress achieved towards meeting goals of care is not being adequately documented.||Evaluations of monitoring systems, effectiveness of interventions and progress towards meeting desired outcomes need to occur and be adequately documented to meet contractual agreements.||PA High||Reporting Complete||08/10/2021|
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: 02 June 2021
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit