Profile & contact details
|Address||163 Hibiscus Coast Highway Red Beach 0932|
|Service types||Dementia care, Geriatric|
|Certification/licence name||Orewa Beach View Retirement Home & Hospital Limited - Solemar|
|Current auditor||The DAA Group Limited|
|End date of current certificate/licence||14 June 2020|
|Certification period||24 months|
|Provider name||Orewa Beach View Retirement Home & Hospital Limited|
|Street address||53B Sentinel Road Herne Bay Auckland 1011|
|Post address||PO Box 147096 Ponsonby Auckland 1144|
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: 16 July 2019
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Each episode of restraint is evaluated in collaboration with the consumer and shall consider: (a) Future options to avoid the use of restraint; (b) Whether the consumer's service delivery plan (or crisis plan) was followed; (c) Any review or modification required to the consumer's service delivery plan (or crisis plan); (d) Whether the desired outcome was achieved; (e) Whether the restraint was the least restrictive option to achieve the desired outcome; (f) The duration of the restraint episode… (this text has been trimmed due to space limits).||The restraint evaluation forms completed by the registered nurse for the residents using a restraint do not contain all the requirements of the restraint minimisation and safe practice standard documented in this criterion. The evaluation forms, as per the restraint minimisation and safe practice policy, have not been completed.||Ensure the appropriate evaluation form is completed as per the restraint policy used by the organisation.||PA Low||Reporting Complete||13/08/2019|
|Entry criteria, assessment, and entry screening processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies.||There is one rest home level resident and two hospital level care residents who are being cared for in the secure dementia unit.||Ensure only residents who have been assessed as requiring dementia level care are admitted to and cared for in the secure dementia care unit.||PA High||Reporting Complete||07/08/2018|
|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).||The residents’ records of three hospital residents currently using a restraint were reviewed. There was no evidence of any assessment being completed to identify any risks, cultural considerations or any history or underlying aetiology for managing any relevant behaviour issues if known prior to any restraint being put in place.||Ensure all residents are comprehensively assessed using the required assessment tool and that the required documentation is completed before restraint is used as a last resort.||PA Moderate||Reporting Complete||06/11/2018|
|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.||The incident/accident completed forms are not filed in the individual resident`s records and an incident log is not maintained in the resident records reviewed as per the incident/accident policy reviewed.||Ensure the original incident/accident forms once relevant information is collated and analysed are filed appropriately in the individual resident`s record and that an incident/accident log is maintained in each resident`s record as per the policy reviewed.||PA Low||Reporting Complete||06/11/2018|
|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.||One resident has had an interval of four and a half months between reviews by the general practitioner. There is no system to identify when routine general practitioner reviews are due. Four residents’ initial nursing assessments have not been completed within 24 hours of admission. Five residents did not have an initial care plan developed to guide care within 24 hours of admission, or the initial care plan could not be located. Two residents admitted in 2018 have not had an interRAI re assessm… (this text has been trimmed due to space limits).||Ensure a system is in place to consistently ensure residents are reviewed by the general practitioner at the frequency documented as required (at least every three months). Ensure initial nursing assessments are undertaken and an initial care plans developed for all residents within 24 hours of admission Ensure an InterRAI reassessment is conducted within 21 days of admission. Ensure referrals are made to the dietitian in a timely manner for applicable residents.||PA Moderate||Reporting Complete||18/12/2018|
|Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.||Records are not available to verify that the service menu plans have been reviewed by a dietitian.||Ensure records are available to demonstrate that menu plans have been reviewed and approved by a dietitian.||PA Low||Reporting Complete||18/12/2018|
|Advance directives that are made available to service providers are acted on where valid.||Persons with Enduring Power of Attorney status are signing not for resuscitation decisions for residents that are not competent to make their own decisions.||Ensure that residents’ Enduring Power of Attorney are not signing the resuscitation decision form on behalf of residents, and that only competent residents are involved in this decision making.||PA Moderate||Reporting Complete||18/12/2018|
|Advance directives that are made available to service providers are acted on where valid.||Persons with Enduring Power of Attorney status are signing not for resuscitation decisions for residents that are not competent to make their own decisions. There was an absence of evidential activated EPOAs on site and the facility manager advised he was not able to get these from some family members despite asking at the time of audit.||Ensure only valid advance directives are acted upon and there is evidence on site of the activated EPOAs.||PA Moderate||In Progress|
|The organisation has a clearly defined and documented infection control programme that is reviewed at least annually.||The service has yet to develop infection prevention and control goals for the service and to have the plan signed off by management.||Ensure the infection prevention and control programme is developed, approved and signed off by management and reviewed annually.||PA Low||Reporting Complete||13/08/2019|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Short term cares plans have not been developed for a resident with significant weight loss. One resident was admitted with two wounds. Wound care plans were not documented for these wounds. At least four residents’ long term care plans were developed or updated before the interRAI re-assessments were completed to inform the care plan requirements.||Ensure short term care plans are consistently developed for new short-term care needs. Ensure wound care plans are consistently documented for residents with wounds. Ensure the outcome from the interRAI reassessments are undertaken in a timeframe to inform changes required to the resident’s long term care plans.||PA Moderate||Reporting Complete||13/08/2019|
|Service providers responsible for medicine management are competent to perform the function for each stage they manage.||The medicine competency records reviewed in staff records did not correspond with the list of staff identified as competent displayed in the medicine room.||Ensure that all staff responsible for checking or administering medicines have current competencies and this information is communicated accurately.||PA Moderate||Reporting Complete||13/08/2019|
|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.||The mandatory completion of a six-monthly stocktake and reconciliation was not done for December 2018 and June 2019 nor any record noted the Controlled Drugs Register. On interviewing the clinical Manager and the Facility Manager they did not appear to know they had to do this nor that there were clear directions of this in the Controlled Drug Record. No system was in place to ensure this was done twice yearly as required.||Provide evidence that all legislative requirements are met and a system is in place regarding medication reconciliation of controlled drugs.||PA Moderate||Reporting Complete||09/09/2019|
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: 16 July 2019
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Provisional Audit