St Clair Park Residential Centre

Profile & contact details

Premises details
Premises nameSt Clair Park Residential Centre
Address 287 Middleton Road Corstorphine Dunedin 9012
Total beds56
Service typesDementia care, Psychiatric, Rest home care
Certification/licence details
Certification/licence nameSt Clair Park Residential Centre Limited - St Clair Park Residential Centre
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence22 September 2021
Certification periodOther months
Provider details
Provider nameSt Clair Park Residential Centre Limited
Street address 287 Middleton Road Corstorphine Dunedin 9012
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: 07 November 2019

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.(i) One resident on respite in the dementia unit did not have interventions in the care plan updated to reflect current behaviours identified. This was amended during the audit. (ii) One resident in the rest home did not have current interventions in place around diabetes management, spirituality, cultural preferences or nursing interventions for pain management. (iii) One resident in mental health under an LTS-CHC contract did not have an up-to date care plan (last reviewed December 20… (this text has been trimmed due to space limits).(i)-(ii) Ensure care plan interventions are reflective of all resident current needs. (iii). Ensure documentation in files is up to date and reflects current needs. PA ModerateReporting Complete17/09/2020
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).Small cluttered office spaces were not identified as a potential hazard in the environmental hazard register. Ensure all hazards are identified and included in the hazard register. PA ModerateReporting Complete30/06/2020
The service demonstrates consumer participation in the planning, implementation, monitoring, and evaluation of service delivery.The service cannot fully demonstrate that consumer participation is evident across all levels of service delivery. Ensure residents have participation in planning, implementation, and monitoring of service delivery. PA LowReporting Complete30/06/2020
The service demonstrates family/whānau and community participation where relevant, in the planning, implementation, monitoring, and evaluation of service delivery.The processes described in policy to involve family in all levels of the service are not fully implemented. Ensure there is family/whānau input into planning, implementation, monitoring and evaluation of service delivery. PA LowReporting Complete30/06/2020
The appointment of appropriate service providers to safely meet the needs of consumers.There has been a high staff turnover and as a result there are currently no staff working in the dementia unit that have completed the dementia standards. The registered nurse providing clinical oversite has little experience working with residents with dementia. Ensure there is sufficient staff experienced in dementia care working in the dementia unit. PA ModerateReporting Complete30/06/2020
The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.(i) There were no progress notes documented following adverse events, wound care, or when a resident was transferred to and from hospital. (ii) There was no documented evidence of registered nurse oversight of residents in the Cargill or Middleton units. Ensure the registered nurse documents all adverse event follow-ups and regular reviews of residents. PA ModerateReporting Complete30/06/2020
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.There was no wound documentation (assessment, plan or evaluation) recorded for a current pressure injury. Ensure all wounds have a wound chart to reflect an assessment, plan and evaluation indication progression towards healing. PA LowReporting Complete30/06/2020
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.One respite resident did not have a drug chart in place for current medications including controlled drugs. Ensure all residents residing at the facility have current drug charts or accompanying documentation in place in line with legislation. PA ModerateReporting Complete30/06/2020
The facilitation of safe self-administration of medicines by consumers where appropriate.There was no self-medicating competency in place for the resident self-administering medications including controlled drugs. Ensure all residents who choose to self-medicate medicines have a competency in place. PA ModerateReporting Complete30/06/2020
All buildings, plant, and equipment comply with legislation.There is no current building warrant of fitness in place. There is a letter on file (dated 1 August 2019) from the Dunedin City Council informing of the building safety and is fit for use, but as regular safety (exit door) checks were not signed as being completed in the last year, a warrant cannot be issued until August 2020. Ensure all compliance checks are completed and a BWOF is issued as directed by the Dunedin City Council. PA LowReporting Complete20/08/2020
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) Two rest home and three dementia incident reports did not evidence clinical assessment or follow-up by the registered nurse was not documented following adverse events. (ii) Neurological observations were not evidenced as occurring following two unwitnessed falls with the potential for a head injury in the dementia unit. (iii) Notifications to the GP were not evident following two medication errors in the rest home unit. There was no documented evidence of notification to the Mental heal… (this text has been trimmed due to space limits).(i) Ensure all adverse events have clinical assessment and follow-up is documented. (ii) Ensure neurological observations are recorded following unwitnessed falls. (ii) Ensure all medication errors are managed to ensure the safety of the resident. PA ModerateReporting Complete20/08/2020
The service develops and implements policies and procedures that are aligned with current good practice and service delivery, meet the requirements of legislation, and are reviewed at regular intervals as defined by policy.Policies and procedures have not been reviewed as planned. Ensure all policies and procedures are reviewed and updated to ensure they align with current practice. PA LowReporting Complete20/08/2020
Consumers have a right to full and frank information and open disclosure from service providers.There was no documented evidence of relative or GP notifications made following adverse events. Ensure all notifications made are documented following adverse events. PA LowReporting Complete20/08/2020

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.

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