St Andrews Home and Hospital

Profile & contact details

Premises details
Premises nameSt Andrews Home and Hospital
Address 8 Easther Crescent Kew Dunedin 9012
Total beds78
Service typesMedical, Dementia care, Geriatric
Certification/licence details
Certification/licence namePresbyterian Support Services Otago Incorporated - St Andrews Home and Hospital
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence16 November 2024
Certification period36 months
Provider details
Provider namePresbyterian Support Otago Incorporated
Street address 407 Moray Street Dunedin 9016
Post addressPO Box 374 Dunedin 9016
Websiteotago.ps.org.nz/

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: 12 June 2023

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
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 ModerateReporting Complete27/01/2022
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 ModerateReporting Complete27/01/2022
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 ModerateReporting Complete27/01/2022
Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care.i) Staff meetings have not been held as scheduled. One bimonthly staff meeting has been held this year in February 2023. Three of five scheduled clinical, performance, quality and wellbeing meetings have been held in January, February, and May 2023. ii) The internal audit schedule (July 2022 – May 2023) evidenced that four of ten internal audits had not been completed. iii) Corrective actions are documented; however do not evidence sign off when completed i) Ensure staff meetings are held as scheduled. ii) Ensure the internal audit schedule is completed as planned. iii) Ensure documented corrective actions evidence completion. PA ModerateIn Progress
Service providers shall engage with people receiving services to assess and develop their individual care or support plan in a timely manner. Whānau shall be involved when the person receiving services requests this.(i) Initial interRAI have not been completed within 21 days for two of five residents. (ii) InterRAI reassessments have not been completed six monthly (outside of the waiver) for one of five residents who required an interRAI assessment. (iii) Initial “getting to know me” assessment was not completed in one of the six resident files. (iv) Three of six resident files reviewed did not have a long-term care plan documented within 21 days of admission. i) Ensure initial interRAI assessments are completed within 21 days. (ii) Ensure repeat interRAI assessments are completed six monthly or more often for residents who require interRAI assessments. (iii) Ensure initial “getting to know me” assessments are completed. within 24 hours of admission. (iv) Ensure residents have a long-term care plan documented within 21 days of admission. PA LowIn Progress
A medication management system shall be implemented appropriate to the scope of the service.(i) Four of twelve residents’ photos on the electronic files had not been reviewed according to PSO policy of at least annually. (ii) The effectiveness of ‘as required’ medication was not consistently documented in either the electronic medication system or the progress notes. (iii) Completion of quality stocktakes has not occurred six-monthly. (i) Ensure all resident photos on the medication chart evidence review as per PSO policy. (ii) Ensure the effectiveness of ‘as required’ medications are documented. (iii) Ensure completion of quality stocktakes occurs. PA ModerateIn Progress
In implementing care or support plans, service providers shall demonstrate: (a) Active involvement with the person receiving services and whānau; (b) That the provision of service is consistent with, and contributes to, meeting the person’s assessed needs, goals, and aspirations. Whānau require assessment for support needs as well. This supports whānau ora and pae ora, and builds resilience, self-management, and self-advocacy among the collective; (c) That the person receives services that remov… (this text has been trimmed due to space limits).(i) Neurological observations were not completed as per policy for three of the six incidents which required monitoring for possible head injuries. (ii) Two of three restraint monitoring charts reviewed evidenced restraint monitoring was not implemented as scheduled or according to policy. (iii) Weight monitoring was not increased following the identification of significant weight loss in two hospital level resident files. (i) Ensure that neurological observations are conducted and recorded as per policy and best practice guideline. (ii) Ensure restraint monitoring is completed as planned and in accordance with policy. (iii) Ensure weight monitoring is completed as instructed. PA LowIn Progress
Planned review of a person’s care or support plan shall: (a) Be undertaken at defined intervals in collaboration with the person and whānau, together with wider service providers; (b) Include the use of a range of outcome measurements; (c) Record the degree of achievement against the person’s agreed goals and aspiration as well as whānau goals and aspirations; (d) Identify changes to the person’s care or support plan, which are agreed collaboratively through the ongoing re-assessment and review … (this text has been trimmed due to space limits).(i) Routine care plan evaluations were not completed within six months for three of four files (two files were not due for review). (ii) Progress towards meeting goals was not identified in two of four files due for review. (i) - (ii) Ensure evaluations are completed at least six monthly, and resident progress towards meeting goals is documented. PA LowIn Progress
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 LowReporting Complete12/09/2023
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).i) Interventions including catheter management are absent in one hospital level care plan. ii) Interventions to manage challenging behaviour are limited in the details for care staff in one hospital and dementia file. iii) Interventions to increase weight monitoring and support the PSO food first strategy are absent in two hospital level residents. i) Ensure interventions including catheter management are included in care plans as necessary. ii) Ensure interventions to manage challenging behaviour are included in care plans for HCAs to follow. iii) Ensure interventions to support weight loss, and increased monitoring of weight including “food first protocols” are included in care plans. PA ModerateReporting Complete22/01/2024
Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services.The service currently does not have sufficient numbers of registered nurses to have an RN on duty on some shifts as per the ARRC contract D17.4 a-i. Ensure there is sufficient RN cover to meet contractual requirements. PA ModerateReporting Complete22/01/2024
Service providers shall understand and comply with statutory and regulatory obligations in relation to essential notification reporting.i) HealthCERT have been notified of one RN staffing shortage; however, this has been an ongoing issue for over a year. ii) An incident involving a resident who absconded with police intervention and required hospitalisation was not notified. i) - ii) Ensure section 31 notifications are completed as required. PA ModerateReporting Complete22/01/2024

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.

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