San Michele Home & Hospital

Profile & contact details

Premises details
Premises nameSan Michele Home & Hospital
Address 175 College Street Te Awamutu 3800
Total beds30
Service typesMedical, Geriatric, Rest home care
Certification/licence details
Certification/licence nameWimbledon Care Limited - San Michele Home & Hospital
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence27 October 2024
Certification period24 months
Provider details
Provider nameWimbledon Care Limited
Street address18 Garden Lane Torbay Auckland 0632
Post address18 Garden Lane Torbay Auckland 0632

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: 30 November 2023

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
The physical environment, internal and external, shall be safe and accessible, minimise risk of harm, and promote safe mobility and independence.There were a number of areas internal and external which were in need of repair to ensure safety and promote independence. The laundry has a sump/sink which is the run off from sinks in the upper-level sinks and the sink in the laundry this was observed to have stagnant water in the bottom. The dirty utility room and the laundry had no clear clean dirty flow. An environmental audit be undertaken and a list be drawn up of all area’s requirement repair, including areas outlined above and a maintenance plan be developed to address the issues. Equipment no longer in use be removed from the facility to allow for a more storage. Storage as a whole be reviewed to ensure areas are not cluttered. The laundry and dirty utility room flow be reviewed to ensure no cross contamination can occur. The garden, external ramps and decks be maintained to ensure they a… (this text has been trimmed due to space limits).PA ModerateReporting Complete09/03/2023
My complaint shall be addressed and resolved in accordance with the Code of Health and Disability Services Consumers’ Rights.Three complaints have occurred since January, there was no evidence of an acknowledgement, or investigation and action being taken. Complainants are not being kept updated on their complaints progress. All complainants have a documented acknowledgement of their issue within the timeframe of the Code. All investigations be undertaken in a timely way and documented. Where the investigation is taking over 20 days to complete the complainant be informed of the delay and the reasons for this. PA ModerateReporting Complete21/02/2023
Service providers shall ensure the quality and risk management system has executive commitment and demonstrates participation by the workforce and people using the service.The managers meeting, attended by the owner is where the data collected would be analysed and trended as a whole. The minutes of the meetings has limited information, with no data from audits being discussed, incidents being reviewed for completion and no corrective actions related to these were sighted in the minutes. The management meeting be the focus of all quality and risk activity and the minutes detail all discussion on these areas and any corrective action requirements be documented for follow up ongoing. PA LowReporting Complete21/02/2023
Service providers shall ensure their health care and support workers have the skills, attitudes, qualifications, experience, and attributes for the services being delivered.There was no evidence that all staff have completed the annual training or have current competencies. The full-time cook has not undertaken training on food safety in the last 15 years, and the nurse manager who has responsibility for infection control has not undertaken training for some time. The annual training plan be reviewed and additional training occur this year to ensure all staff can undertake appropriate training The full-time cook and nurse manager undertake further training related to their roles, in food safety and infection control. PA LowReporting Complete21/02/2023
Service providers shall develop and implement policies and procedures in accordance with good employment practice and meet the requirements of legislation.Staff files reviewed do not contain all relevant information related to good employment practices All the requirements of good employment practice including legal requirement for police checking be undertaken PA ModerateReporting Complete21/02/2023
Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided.There was no evidence that all staff have undertaken and had sign off for orientation. All staff complete their orientation workbook and this be added to their personnel files. PA ModerateReporting Complete21/02/2023
Planned review of a person’s care or support plan shall: (a) Be undertaken at defined intervals in collaboration with the person and whānau, together with wider service providers; (b) Include the use of a range of outcome measurements; (c) Record the degree of achievement against the person’s agreed goals and aspiration as well as whānau goals and aspirations; (d) Identify changes to the person’s care or support plan, which are agreed collaboratively through the ongoing re-assessment and review … (this text has been trimmed due to space limits).Residents care plans do not always identify changes to the resident’s care during the assessment and ongoing review process to ensure changes are implemented. Where progress is different from expected, changes are not always initiated. Post fall neurological assessments are not managed in line with best practice guidelines. Specialists input had not been sought for a wound that wasn’t healing. The appearance of a bruise, and no evidence of a fall, has no nursing review of the resident’s medicati… (this text has been trimmed due to space limits).Provide evidence care plans identify changes to the resident’s care through the ongoing assessment and review process and ensure changes are implemented. Where progress is different from expected, changes are initiated. Care plans are required to identify strategies to manage residents identified problems and include the nursing strategies required to manage these problems. Specialist input is required to be sought when there is evidence the present management regime is not achieving the desired… (this text has been trimmed due to space limits).PA ModerateReporting Complete21/02/2023
A medication management system shall be implemented appropriate to the scope of the service.Medications at San Michele are not evidenced to be stored safely. Fridge temperatures for storing medication are are not maintained within the required range. This however was being addressed on the day of audit. The medication fridge requires to be defrosted on a regular basis to eliminate ice build-up. The temperature of the medication room is not monitored to ensure the medications are stored within the required range. Residents who self-administer medications have no documentation in place t… (this text has been trimmed due to space limits).Provide evidence that medications are stored within the required temperatures, with fridge and room temperatures monitored to evidence medication are stored within the required temperature ranges. Provide evidence that residents who self-administer medications can do so safely. Remove outdated supplies from the medication room. PA ModerateReporting Complete21/02/2023
There shall be adequate space to allow people to move safely around their personal space and bed area.There are two three bedded hospital rooms with limited space for residents to mobilise safely around the room. The space was limited with the door at one end, staff had to move beds to get the hoist to the third resident. The space available for residents in the three bedded room be reassessed to; ensure privacy and adequate space for residents with mobility aids to move around freely and the use of a hoist be possible without moving beds. PA LowReporting Complete09/03/2023
Service providers shall have a clearly defined and documented IP programme that shall be: (a) Developed by those with IP expertise; (b) Approved by the governance body; (c) Linked to the quality improvement programme; and (d) Reviewed and reported on annually. There is no clearly defined infection prevention programme that is developed by those with infection prevention expertise, and reviewed annually Provided evidence there is an infection control programme in place, that is developed with infection prevention expertise, and is reviewed annually. PA ModerateReporting Complete09/03/2023
Service providers shall ensure there are safe and effective laundry services appropriate to the size and scope of the health and disability service that include: (a) Methods, frequency, and materials used for laundry processes; (b) Laundry processes being monitored for effectiveness; (c) A clear separation between handling and storage of clean and dirty laundry; (d) Access to designated areas for the safe and hygienic storage of laundry equipment and chemicals. This shall be reflected in a writt… (this text has been trimmed due to space limits).There is no clear line for the handling of dirty and clean laundry. The laundry process sighted does not minimise the potential for infection and meet best practice guidelines. Provide evidence processes are in place to ensure safe and effective laundering services are provided. PA ModerateReporting Complete09/03/2023
Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care.i). Audits are not signed off as being complete. ii). Corrective actions are not documented when required. i). – ii). Ensure audits are signed off when complete and corrective actions are documented and implemented where required. PA LowIn Progress
Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services.The service does not have sufficient numbers of registered nurses to have an RN on duty at all times as per the ARC contract D17.4 a. i. Ensure a registered nurse is on duty at all times to meet the requirements of the ARC contract D17.4 a. i. PA LowIn Progress
Service providers shall identify external and internal risks and opportunities, including potential inequities, and develop a plan to respond to them.i). Seven of 10 incident forms reviewed were not fully completed/signed off. ii). Incident reports reviewed for four hospital and three rest home residents did not evidence family/whānau were informed of the incident, or the reason for not informing family/whānau (resident request). i). Ensure incident forms are fully completed/signed off. ii). Ensure there is documented evidence that relatives are informed incidents, or the reason relatives were not informed (resident request). PA ModerateIn Progress
A medication management system shall be implemented appropriate to the scope of the service.i). Medications were stored in a medication room and trolley; however, both were unlocked during audit, with the medication door left open, and medications (including returns to pharmacy) left unattended on a bench within the open room. ii). Oxygen cylinders were not secured safely within the medication room. iii). There were no regular checks of controlled medications documented in the register. iv). The medication fridge and medication room temperatures have been monitored daily and the temp… (this text has been trimmed due to space limits).i). – iii). Ensure safe storage and medication checks are carried out as per policy and best practice requirements. iv). Ensure safe storage and medication checks are carried out as per policy and best practice requirements. PA HighIn Progress
The following aspects of the system shall be performed and communicated to people by registered health professionals operating within their role and scope of practice: prescribing, dispensing, reconciliation, and review.i). The RN was observed to have pre-dispensed the medications from the blister packs into pottles in the medication room. ii). The medication chart was signed off as administered in the medication room prior to administration. iii). Medications were left with residents to take later (this included a controlled medication). i).- iii). Ensure all staff follow policy and safe practice when administering medications PA HighIn Progress
Planned review of a person’s care or support plan shall: (a) Be undertaken at defined intervals in collaboration with the person and whānau, together with wider service providers; (b) Include the use of a range of outcome measurements; (c) Record the degree of achievement against the person’s agreed goals and aspiration as well as whānau goals and aspirations; (d) Identify changes to the person’s care or support plan, which are agreed collaboratively through the ongoing re-assessment and review … (this text has been trimmed due to space limits).Three of 10 incident reports reviewed did not evidence neurological observations were completed according to policy. Ensure neurological observations are completed as per policy. PA ModerateIn Progress
A process shall be implemented to identify, record, and communicate people’s medicinerelated allergies or sensitivities and respond appropriately to adverse events.Four of the eleven medication charts reviewed did not have the allergy status completed. Ensure all residents have their allergy status completed on the electronic medication chart. PA ModerateIn Progress
Surveillance methods, tools, documentation, analysis, and assignment of responsibilities shall be described and documented using standardised surveillance definitions. Surveillance includes ethnicity data.Ethnicity data is not being collated and analysed during infection surveillance. Ensure ethnicity data is collated and analysed during infection surveillance. 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. 

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.

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