Sheaffs Rest Home

Profile & contact details

Premises details
Premises nameSheaffs Rest Home
Address 17 Landing Road Whakatane 3120
Total beds29
Service typesRest home care
Certification/licence details
Certification/licence nameEllora Enterprises Limited - Sheaffs Rest Home
Current auditorHealthShare Limited
End date of current certificate/licence07 August 2019
Certification period36 months
Provider details
Provider nameEllora Enterprises Limited
Street address 17 Landing Road Whakatane 3120
Post address

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: 14 December 2017

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Infection control education is provided by a suitably qualified person who maintains their knowledge of current practice.The infection control coordinator has not attended training around infection prevention and control in the past two years. Ensure the infection control coordinator maintains a current knowledge of infection control best practice PA LowReporting Complete30/11/2016
The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk.i) An incident form was not completed for one episode of aggressive behaviour. ii) Two residents with recent incidents of aggressive behaviour involving other residents and staff, did not have clear interventions documented in the care plans. i) Ensure that all incidents have an incident form documented. ii) Ensure that challenging behaviours are addressed in the care plan. PA ModerateReporting Complete30/11/2016
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.Instructions for the administration of variable doses of warfarin have been transcribed on to administration signing sheets. Cease the practice of transcribing medication orders. PA ModerateReporting Complete30/11/2016
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Staff have not completed recent training around infection control, chemical safety, cultural care, skin care and behaviours that challenge. Ensure that staff complete all required and relevant training. PA LowReporting Complete22/03/2017
Protective equipment and clothing appropriate to the risks involved when handling waste or hazardous substances is provided and used by service providers.On audit of the laundry, there were no face protection readily available for staff to use. Ensure personal protective equipment and clothing appropriate to the risks involved when handling waste or hazardous substances is provided and used by service providers. PA LowReporting Complete30/05/2017
Service providers responsible for medicine management are competent to perform the function for each stage they manage.The registered nurse has not completed a medication competency to date. Ensure that any staff who administer medication have a competency completed annually. PA ModerateIn Progress
Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.Stock takes of controlled drugs have not been completed in the last three months as per policy. Complete stock takes of controlled drugs as per policy. PA LowIn Progress
The appointment of appropriate service providers to safely meet the needs of consumers.Two of the staff files reviewed do not have documentation of evidence of criminal vetting. Ensure that each staff member is criminally vetted prior to appointment. PA NegligibleIn Progress
All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.i) One fridge is not checked to ensure that the temperature is within normal range. ii) Recordings of the freezer temperature do not confirm that the temperature is within normal range at all times. iii) Temperatures of cooked food are not taken. iv) Confirmation of food safety training for the cooks was not able to be sighted on the day of audit. v) The resident’s dietary assessment is not reviewed six monthly as part of the reassessment and review of care plans. Ensure that all fridges are checked to ensure that the temperature is within normal range. Ensure that the temperature of the freezer is within normal range. Ensure that temperatures of hot food are taken to check that food is thoroughly cooked through. Ensure that each cook completes food safety training. Review the dietary assessments as part of the review of care plans at six monthly intervals. PA ModerateIn Progress
All buildings, plant, and equipment comply with legislation.Medical equipment has not been calibrated in the past 12 months. Ensure that medical equipment is calibrated annually as planned. 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.

Audit reports

Audit date: 14 December 2017

Audit type:Surveillance Audit

Audit date: 18 May 2016

Audit type:Certification Audit

Audit date: 22 January 2015

Audit type:Surveillance Audit

Audit date: 05 June 2013

Audit type:Certification Audit

Audit date: 09 November 2011

Audit type:Surveillance Audit

Audit date: 14 June 2010

Audit type:Certification Audit

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