San Michele Home and Hospital

Profile & contact details

Premises details
Premises nameSan Michele Home and Hospital
Address 175 College Street Te Awamutu 3800
Total beds30
Service typesMedical, Rest home care, Geriatric
Certification/licence details
Certification/licence nameStanthom Properties Limited - San Michele Home and Hospital
Current auditorThe DAA Group Limited
End date of current certificate/licence02 November 2021
Certification period24 months
Provider details
Provider nameStanthom Properties Limited
Street address 31 Pukehana Avenue Epsom Auckland 1023
Post addressPO Box 28853 Remuera Auckland 1541

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: 29 August 2019

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
A process to measure achievement against the quality and risk management plan is implemented.There is no current quality plan. The internal audit system is failing to identify issues and/or gaps in service delivery. Develop a goal focused quality plan as required in the ARC contract. Review the internal audit tools and system and implement actions to improve the effectiveness of audits. PA ModerateIn Progress
The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code.Complaints are not being managed according to the documented policy and procedures. Ensure that complaint processes are followed as per policy. PA LowIn Progress
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.The two people with the ultimate responsibility for clinical care and service leadership have not had any formal feedback on their performance. Ensure the senior RN and nurse manager are provided the opportunity for performance feedback and performance goal setting. PA ModerateIn Progress
All buildings, plant, and equipment comply with legislation.Bio medical equipment is not being checked, calibrated (if required) or regularly maintained. Ensure that all medical equipment is regularly tested and/or calibrated for accuracy. PA ModerateIn Progress
The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.A stage 4 pressure injury was not notified to the DHB or the Ministry of Health as required under Section 31. Ensure that essential notifications are reported according to Ministry of Heath guidelines and Section 31 requirements. PA ModerateIn 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.InterRAI assessments are not being completed before the long-term care plans are developed nor do they identify all the needs of the resident. Ensure that issues identified during the assessment process are used to inform the long-term care plans. PA ModerateIn Progress
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.Six of six residents’ long term care plans reviewed lacked the required detail and did not highlight all of the residents’ needs and/or did not contain the information/presenting issues identified by the referrers. Ensure that care plans reflect the needs and care required identified by the referrer and the assessment process. PA ModerateIn Progress
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.Two residents’ three monthly GP reviews booked for June and July are overdue. Ensure that all GP reviews are up to date. PA LowIn Progress

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. 

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.

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