St Andrews Home and Hospital
Profile & contact details
|Premises name||St Andrews Home and Hospital|
|Address||8 Easther Crescent Kew Dunedin 9012|
|Service types||Dementia care, Geriatric, Medical|
|Certification/licence name||Presbyterian Support Services Otago Incorporated - St Andrews Home and Hospital|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||16 November 2024|
|Certification period||36 months|
|Provider name||Presbyterian Support Otago Incorporated|
|Street address||407 Moray Street Dunedin 9016|
|Post address||PO Box 374 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: 16 September 2021
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Two of ten staff files reviewed did not evidence completed orientation documentation.||Ensure that all new staff complete appropriate orientation and that this is documented.||PA Low||In Progress|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||The following shortfalls were identified: (a) Related to behaviour management: i) one hospital resident with anxiety medication management strategies were not identified; ii) one hospital level resident and one in the dementia had recurrent behaviour, however triggers and when behaviours are likely occurring were not identified; iii) One resident (ACC) type of behaviour and interventions to manage was not recorded in the care plan. (b) Related to management of swallowing difficulties: i) one hos… (this text has been trimmed due to space limits).||(a)-(c) Ensure residents long-term care plan reflects the current need of the resident and the required intervention to support those needs.||PA Moderate||Reporting Complete||27/01/2022|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||a). Annual Medication management training for registered nurses and medication competent care workers has not been provided since 2018. b). Three of 15 care workers who work in the dementia unit have not completed the required dementia unit standards within 18 months of employment.||a). Provide evidence that medication management and safe administration has been provided for all staff with medication administration responsibilities. b). Provide evidence that all care workers who work in the dementia unit complete the required dementia unit standards within the expected timeframes.||PA Moderate||Reporting Complete||27/01/2022|
|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.||Eight medication errors reported during July and August 2021 have not been followed up, and corrective actions with staff involved have not been implemented.||Ensure that all medication errors are appropriately managed in a timely manner with staff involved.||PA Moderate||Reporting Complete||27/01/2022|
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: 16 September 2021
Audit type:Certification Audit
- St Andrews Home and Hospital - Sep 2021 (docx, 53.06 KB)
- St Andrews Home and Hospital - Sep 2021 (pdf, 210.15 KB)
Audit type:Certification Audit
- St Andrews Home and Hospital - Sep 2018 (docx, 47.97 KB)
- St Andrews Home and Hospital - Sep 2018 (pdf, 187.3 KB)
Audit type:Surveillance Audit