South Care Rest Home & Hospital
Profile & contact details
| Premises name | South Care Rest Home & Hospital |
|---|---|
| Address | 1027 George Street North Dunedin Dunedin 9016 |
| Total beds | 62 |
| Service types | Intellectual, Rest home care, Medical, Physical, Geriatric |
| Certification/licence name | South Care Limited - South Care Rest Home & Hospital |
|---|---|
| Current auditor | The DAA Group Limited |
| End date of current certificate/licence | 27 November 2024 |
| Certification period | 36 months |
| Provider name | South Care Limited |
|---|---|
| Street address | 1027 George Street North Dunedin Dunedin 9016 |
| Post address | 1027 George Street North Dunedin Dunedin 9016 |
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: 13 April 2023
| Outcome required | Found at audit | Action required | Risk rating | Action status | Date action reported complete |
|---|---|---|---|---|---|
| The appointment of appropriate service providers to safely meet the needs of consumers. | In six of nine personnel files reviewed, there is no record of receipt of the police vetting result recorded. | Implement a system to ensure that receipt of police vetting results are recorded on the personnel file. | PA Low | Reporting Complete | 16/06/2022 |
| Where required by legislation there is an approved evacuation plan. | There is no record available for a current and approved Fire Evacuation Plan for the facility. | Maintain a record of a current approved Fire Evacuation Plan for the facility. | PA Low | Reporting Complete | 16/06/2022 |
| Alternative energy and utility sources are available in the event of the main supplies failing. | The chef is charged with managing the emergency food supply, which was stated to be stored in the kitchen storeroom. Sufficient food for use in an emergency was not sighted during the audit. The chef stated this is not required as food deliveries can occur twice a day if required. No evidence was presented of a system to purchase food in suitable quantities or store and manage food for emergency situations. | There is a system in place to purchase, store and rotate sufficient food items for emergency use to meet the needs of the residents for a period of at least three days. | PA Moderate | Reporting Complete | 16/06/2022 |
| The methods, frequency, and materials used for cleaning and laundry processes are monitored for effectiveness. | Processes and practice for managing the cleaning of mops and buckets are not adequate to ensure effective infection prevention. | Implement suitable cleaning and drying processes for mops and buckets. | PA Low | Reporting Complete | 16/06/2022 |
| The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate. | Although verbal handovers do occur between shifts, written handover documentation (history and changes in care needs) is not consistently available to staff e.g., those staff returning from leave. Resident documentation sighted at audit was not fully complete and did not support continuity of care e.g., enabler use and challenging behaviour. | The service is coordinated in a manner that provides continuity in service delivery including current documentation to guide care. | PA Low | Reporting Complete | 16/06/2022 |
| Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include: (a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk; (b) A process that addresses/treats the risks associated with service provision is developed and im… (this text has been trimmed due to space limits). | The frequency of review of identified risks does not reflect the significance of, or any changes in risk which may be occurring. Apart from health and safety and hazards, wider organisational risks are not explicitly discussed or reviewed at the various meetings. | Further development is required to ensure that risks are reviewed at a frequency determined by the severity of the risk and the probability of changes in the status of the risk. | PA Low | Reporting Complete | 16/06/2022 |
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | There is a lack of documented evidence to verify that areas identified as requiring improvement within the quality and risk management system have been addressed, or if recommendations from satisfaction survey outcomes have been implemented. | There is clear evidence of the follow-up actions taken to address the areas identified as requiring improvement within the quality and risk management system. | PA Low | In Progress | |
| Buildings, plant, and equipment shall be fit for purpose, and comply with legislation relevant to the health and disability service being provided. The environment is inclusive of peoples’ cultures and supports cultural practices. | Some aspects of the environment are presenting potential safety risks for residents, including for injury and/or infection. | A time-framed renovation plan that will ensure the facility is safe and fit for purpose is developed and subsequently implemented. | PA Moderate | In Progress | |
| A medication management system shall be implemented appropriate to the scope of the service. | Not all elements of the medication management system as implemented meet the expected standard for storage and labelling of medications to ensure safe administration. • Prescribed inhalers were not stored in the original pharmacy packaging and did not contain a label with the required information including residents’ names and prescription details. • Eye drops being administered to a resident were not labelled with the resident name and did not show prescription details. • Eye drops and eye oin… (this text has been trimmed due to space limits). | Ensure all medications are labelled to ensure safe administration of medication including: • All inhalers and eye drop bottles are labelled with a pharmacy label to identify the resident and show prescription details. • All eye drop bottles and ointments are labelled with the resident’s name and the date of opening once in use. • All oxygen cylinders are securely stored. | PA Moderate | In Progress | |
| Fundamental to the development of a care or support plan shall be that: (a) Informed choice is an underpinning principle; (b) A suitably qualified, skilled, and experienced health care or support worker undertakes the development of the care or support plan; (c) Comprehensive assessment includes consideration of people’s lived experience; (d) Cultural needs, values, and beliefs are considered; (e) Cultural assessments are completed by culturally competent workers and are accessible in all settin… (this text has been trimmed due to space limits). | Care planning is based on the assessed need of the residents. However, in five of five residents’ files reviewed the resident’s individual strengths, goals and aspirations were not identified and supports required to meet the resident’s individual goals were not documented; this included goals for both physical and social/cultural needs. | Ensure all residents’ personal strengths, goals and aspirations are identified in relation to physical needs, social/cultural needs and their values and beliefs. Ensure supports to meet the residents’ individual goals and aspirations are documented in the care plan. | PA Moderate | In Progress | |
| Service providers shall ensure there is a system to identify, plan, facilitate, and record ongoing learning and development for health care and support workers so that they can provide high-quality safe services. | Not all mandatory core training requirements of support workers have been completed within the required timeframes. | The staff training system ensures all mandatory staff training requirements are fulfilled within required timeframes. | PA Low | In Progress | |
| Prior to a Māori individual and whānau entry, service providers shall: (a) Develop meaningful partnerships with Māori communities and organisations to benefit Māori individuals and whānau; (b) Work with Māori health practitioners, traditional Māori healers, and organisations to benefit Māori individuals and whānau. | The service has not yet developed meaningful partnerships with Māori communities and organisations to benefit Māori residents and their whānau and does not have connections in place to access Māori health practitioners or traditional healers if requested. | Develop meaningful partnerships with Māori communities and organisations to benefit Māori residents and whānau ensuring connections are in place to access Māori health practitioners and traditional healers. | PA Low | In 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.
Audit reports
Audit date: 13 April 2023Audit type:Surveillance Audit
- South Care Rest Home & Hospital - Apr 2023 (docx, 59.42 KB)
- South Care Rest Home & Hospital - Apr 2023 (pdf, 180.79 KB)
Audit type:Certification Audit
- South Care Rest Home & Hospital - Sep 2021 (docx, 49.69 KB)
- South Care Rest Home & Hospital - Sep 2021 (pdf, 188.61 KB)
Audit type:Provisional Audit