Ross Home and Hospital

Profile & contact details

Premises details
Premises name	Ross Home and Hospital
Address	360 North Road North East Valley Dunedin 9010
Total beds	124
Service types	Psychogeriatric, Geriatric, Medical, Rest home care

Certification/licence details
Certification/licence name	Presbyterian Support Services Otago Incorporated - Ross Home and Hospital
Current auditor	Health and Disability Auditing New Zealand Limited
End date of current certificate/licence	16 September 2024
Certification period	36 months

Provider details
Provider name	Presbyterian Support Otago Incorporated
Street address	407 Moray Street Dunedin 9016
Post address	PO Box 374 Dunedin 9016
Website	otago.ps.org.nz/

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: 24 June 2021

Outcome required	Found at audit	Action required	Risk rating	Action status	Date action reported complete
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.	A review of staff meeting minutes in four of the five wings failed to reflect evidence of quality results being communicated to staff (e.g., internal audit results, adverse event data, benchmarked results, and complaints (if any). It is also noted that three monthly staff meetings do not allow for the timely reporting of quality results.	Ensure staff are kept informed of quality results in a timely manner.	PA Low	Reporting Complete	18/01/2022
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.	Eight of twenty-three care workers who work in the PG unit have not completed all required unit standards (or equivalent) within the acceptable timeframes.	Ensure all required unit standards are completed for those care workers who are employed to work in the PG unit.	PA Low	Reporting Complete	18/01/2022
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.	Two of four residents in the rest home did not have an initial interRAI assessment completed after admission within the required timeframe.	Ensure InterRAI assessments are completed within the required timeframes	PA Low	Reporting Complete	18/01/2022
The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.	Hot water temperature monitoring of resident taps is not routinely being monitored.	Ensure records reflect resident water taps that are routinely checked with temperatures maintained below 45 degrees Celsius.	PA Low	Reporting Complete	18/01/2022
Approved restraint is only applied as a last resort, with the least amount of force, after alternative interventions have been considered or attempted and determined inadequate. The decision to approve restraint for a consumer should be made: (a) Only as a last resort to maintain the safety of consumers, service providers or others; (b) Following appropriate planning and preparation; (c) By the most appropriate health professional; (d) When the environment is appropriate and safe for successful … (this text has been trimmed due to space limits).	In one resident record, restraint was initiated between 9am and 11am for falls prevention. The rationale for this was prevention of a fall when staff were busy undertaking other residents’ personal cares. This was discussed with family /whānau, and they have consented to use restraint particularly at these times and as required. This was also confirmed by the staff.	Ensure that restraint is used as a last resort and not used to manage staff availability.	PA Low	Reporting Complete	18/01/2022
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.	The following shortfalls were identified: i) Blood sugar monitoring for two rest home (including tracer) was not completed within the stated timeframes including one blood sugar level recorded was outside the normal parameters with no linked or recorded corrective action. ii) Restraint monitoring for two residents (one in the hospital [ tracer] and one psychogeriatric unit) restraint monitoring for a bedrail and lap belt was not completed within the timeframes and gaps in recording times for app… (this text has been trimmed due to space limits).	Ensure all monitoring is completed as instructed by the care plan.	PA Moderate	Reporting Complete	13/04/2022

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.

From 1 June 2009 to 28 February 2022 rest homes were audited against the Health and Disability Services Standards NZS 8134:2008. These standards have been updated, and from 28 February 2022 rest homes are audited against Ngā Paerewa Health and Disability Services Standard NZS 8134:2021.

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 Ngā Paerewa Health and Disability Services Standard.

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: 24 June 2021

Audit type:Certification Audit

Audit date: 08 October 2019

Audit type:Surveillance Audit

Audit date: 22 June 2017

Audit type:Certification Audit

Audit date: 22 March 2016

Audit type:Surveillance Audit

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