Rossendale Dementia Care Home & Hospital
Profile & contact details
|Premises name||Rossendale Dementia Care Home & Hospital|
|Address||2 Insoll Avenue Enderley Hamilton 3214|
|Service types||Dementia care, Psychogeriatric|
|Certification/licence name||Bupa Care Services NZ Limited - Rossendale Dementia Care Home & Hospital|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||14 March 2023|
|Certification period||48 months|
|Provider name||Bupa Care Services NZ Limited|
|Street address||Level 2 109 Carlton Grove Road Newmarket Auckland 1023|
|Post address||PO Box 113054 Newmarket Auckland 1149|
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: 21 January 2021
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Key components of service delivery shall be explicitly linked to the quality management system.||(i). Not all audits have been completed as per schedule, this included: First impressions (June), activities (July), care planning, and emergency procedure (November). The clinical file audit for September was commenced but not completed. (ii). The mattress checks required by the DHB have not been documented as implemented. (iii). Service meetings have not occurred as per the meeting schedule, this includes staff meetings (none since September). Quality meetings were evidenced only for June, J… (this text has been trimmed due to space limits).||(i). Ensure that internal audits are completed as per schedule. (ii). Ensure that mattress checks are scheduled and implemented. (iii). Ensure meetings are held to ensure communication of quality outcomes to staff||PA Moderate||Reporting Complete||21/07/2021|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||There was no documentation to reflect that five caregivers who have been employed over 18-months had completed dementia standards training.||Ensure that documentation reflects that all caregivers that work in the PG and dementia units have completed the required dementia standards.||PA Low||Reporting Complete||26/04/2019|
|All buildings, plant, and equipment comply with legislation.||Over the previous three months, several recordings in different areas have been documented between 45 and 55 degrees. The service contacted a plumber to address on the day of audit.||Ensure all hot water temperatures in resident areas are maintained below 45 degrees.||PA Low||Reporting Complete||26/04/2019|
|Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.||(i). Fire evacuation notices were not on walls above all fire call points where they were observed, they were out of date. (ii). There was no unit or directional signage to aid staff, residents and visitors should an emergency evacuation be necessary. (iii). There was no documented fire evacuation for the due date of September 2020.||(i)-(ii). Ensure fire evacuation notices and directional signage are in place in all areas of the building. (iii). Complete and evidence an emergency evacuation six monthly.||PA Moderate||Reporting Complete||21/07/2021|
|Consumers are provided with safe and accessible external areas that meet their needs.||Residents were unable to freely access external areas.||Ensure all residents are free to access external areas at a time of their choosing.||PA Moderate||Reporting Complete||21/07/2021|
|Service providers responsible for medicine management are competent to perform the function for each stage they manage.||Not all staff (three registered nurses and three caregivers) who administer medications have an up-to-date medication competency.||Ensure all staff who administer medication have a current medication competency.||PA Moderate||Reporting Complete||21/07/2021|
|The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code.||Three complaints received from family members during 2020 did not have an acknowledgement letter or a follow-up/closure letter on file.||Ensure that the complaints process follows the formal Bupa policy/procedure.||PA Low||Reporting Complete||21/07/2021|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||(i). There are 33 staff members who have been employed over 18-months who have not completed the required dementia unit standards. (ii). Staff appraisals were not up to date for five of five staff members who had been employed for over a year. (iii). Training such as falls prevention and pain management have been provided according to staff, but this has not documented as being completed.||(i). Ensure that all caregivers that work in the PG and dementia units have completed the required dementia standards within the required time as per the ARHSS and ARCC contracts. (ii). Ensure that staff have an annual appraisal. (iii). Ensure that all training is documented as completed including falls prevention and pain management.||PA Moderate||Reporting Complete||21/07/2021|
|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.||Four of five resident files (under ARCCS/ARHSS contracts) showed long-term care plans and interRAI assessments were not always completed within the timeframes stated in policy. (i). Two new interRAI and long-term care plans were not completed within the timeframes stated in policy. (ii). Three routine interRAI and long-term care plans were not completed within the timeframes stated in policy. (iii). Three resident care plans reviewed had not been evaluated by the registered nurses six-monthly … (this text has been trimmed due to space limits).||(i)-(iii). Ensure all interRAI assessments and care plans are developed and reviewed within the required timeframes according to policy.||PA Moderate||Reporting Complete||21/07/2021|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||(i). Three of four PG resident care plans reviewed did not document the use of and the risks associated with using restraint or monitoring timeframes. (ii) One dementia resident care plan did not evidence the timeframes for blood sugar testing or the signs, symptoms and management plan for hypoglycaemia as advised by the dietitian.||(i)-(ii). Ensure all care plans evidence risks associated with restraint use and detail appropriate timescales for monitoring issues impacting resident care.||PA Moderate||Reporting Complete||21/07/2021|
|The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.||(i). There was broken and uneven walking areas in one unit posing a trip hazard. (ii). There was broken furniture and potting mix accessible to confused residents causing a health and safety hazard.||(i). Ensure all outdoor areas are safe and that walking paths are well maintained. (ii). Ensure that hazardous substances are secured, and that broken and unsafe furniture is stored away from resident areas.||PA Moderate||Reporting Complete||21/07/2021|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i). Three of six resident charts showed neurological observations were not completed according to policy. (ii). Ten of ten fluid balance charts were not consistently or fully completed. (iii). Two resident positioning charts were not consistently completed. (iv). Restraint monitoring charts were not consistently or fully completed. (v). Four intentional rounding charts and behaviour monitoring charts were not fully completed or completed in a timely manner.||(i)-(v).Ensure all resident monitoring charts are fully completed in a timely manner and according to policy.||PA Moderate||Reporting Complete||21/07/2021|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||It was observed during the audit walk arounds that residents in communal areas are not always supervised||Adequately and consistently supervise vulnerable residents in communal spaces||PA Moderate||Reporting Complete||21/07/2021|
|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).||One resident in the HDU was confined to a room (by a chair blocking the exit to the room). There was no assessment for this restraint and/or consent. This was not an approved form of environmental restraint.||Ensure that all residents with restraint have an assessment and consent according to Bupa policies. Ensure only approved forms of restraint are used.||PA Moderate||Reporting Complete||21/07/2021|
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: 21 January 2021
Audit type:Surveillance Audit
- Rossendale Dementia Care Home & Hospital - Jan 2021 (docx, 42.52 KB)
- Rossendale Dementia Care Home & Hospital - Jan 2021 (pdf, 168.08 KB)
Audit type:Certification Audit
- Rossendale Dementia Care Home & Hospital - Jan 2019 (docx, 48.49 KB)
- Rossendale Dementia Care Home & Hospital - Jan 2019 (pdf, 191.54 KB)
Audit type:Surveillance Audit
- Rossendale Dementia Care Home & Hospital - Mar 2017 (docx, 35.8 KB)
- Rossendale Dementia Care Home & Hospital - Mar 2017 (pdf, 142.74 KB)
Audit type:Certification Audit