Profile & contact details
|Premises name||Sevenoaks Lodge|
|Address||Sevenoaks Lodge 1 Lodge Drive Paraparaumu Beach Paraparaumu 5032|
|Service types||Dementia care, Rest home care, Geriatric, Medical|
|Certification/licence name||Kapiti Retirement Trust - Sevenoaks Lodge|
|Current auditor||The DAA Group Limited|
|End date of current certificate/licence||25 June 2024|
|Certification period||36 months|
|Provider name||Kapiti Retirement Trust|
|Street address||Lodge Drive Paraparaumu Beach Paraparaumu 5032|
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: 23 March 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.||When reviewing the minutes from each meeting they are not recording all the details which are being discussed at the meeting and a complete record of all quality improvement data is not being retained.||Ensure that those staff members who are required to report on quality improvement data provide the data on the report template, and the minutes record the discussion of the data.||PA Low||Reporting Complete||10/02/2022|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Although the meetings have been regular, the minutes do not record any analysis and evaluation of what the data. When interviewed, the three clinical managers and the GMRW agreed that, during 2020 and until the audit, there has been little or no analysis and/or evaluation of the data overall. Staff who were interviewed reported their involvement in quality and risk management activities through the reporting of events, hazards and receiving feedback about events they report. However, those s… (this text has been trimmed due to space limits).||Ensure that the analysis and evaluation quality improvement data occurs during the Quality Committee meeting and the RN/EN meeting as appropriate.||PA Moderate||Reporting Complete||10/02/2022|
|Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.||The menu at Sevenoaks has not been verified within the past two years as meeting the nutritional guidelines/needs of older people.||Provide evidence the menu at Sevenoaks meets the nutritional guidelines for the needs of older adults.||PA Low||Reporting Complete||10/02/2022|
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.
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 reportsAudit date: 23 March 2021
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit