St Joseph's Home & Hospital
Profile & contact details
|Premises name||St Joseph's Home & Hospital|
|Address||9 Tweed Street Herne Bay Auckland 1011|
|Service types||Rest home care, Geriatric, Medical|
|Certification/licence name||Little Sisters of The Poor Aged Care New Zealand Limited - St Joseph's|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||13 July 2022|
|Certification period||36 months|
|Provider name||Little Sisters of The Poor Aged Care New Zealand Limited|
|Street address||295 Brockville Road Brockville Dunedin 9011|
|Post address||PO Box 47276 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: 13 May 2019
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i) There was incomplete documented evidence of nephrostomy catheter tube changes for one hospital resident that had a nephrostomy tube in place. (ii) Neurological observations had not been completed for two residents with unwitnessed falls as per policy. (iii) A sample of caregiver interviews confirmed that they are single-handedly using the hoist to transfer residents approximately three to four times per week. (iv) Residents using restraint or enablers are required to have this documented … (this text has been trimmed due to space limits).||(i) Ensure nephrostomy catheter tubes are changed as prescribed, and the dates and times documented. (ii) Ensure neurological observations are completed for unwitnessed falls. (iii) Ensure a minimum of two persons are always present during hoist transfers. (iv) Ensure restraint use is documented in the care plans of all residents using restraint.||PA Moderate||Reporting Complete||22/10/2019|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||The complaints register for 2018 and 2019 (year to date) failed to include all actions taken (eg, acknowledgement of the complaint, investigation of the complaint). All of these complaints were documented as resolved.||Ensure the complaints register includes not only the complaint, but all dates and actions taken.||PA Low||Reporting Complete||22/10/2019|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||i) Meeting minutes do not reflect evidence of quality results being communicated to staff (eg, internal audit results, adverse events, infections). ii) Meeting minutes are not posted for staff to read if they miss the meeting. iii) Although individual comments were addressed in the last resident survey results, they were not collated and analysed to identify trends and possible areas for improvements.||i) Ensure meeting minutes reflect quality results being communicated to staff. ii) Ensure meeting minutes are readily available to staff. iii) Ensure resident satisfaction survey results are collated and analysed to ensure that areas requiring improvements are identified.||PA Low||Reporting Complete||22/10/2019|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Three out of nine internal audits completed over the past year indicated that improvements were required (restraint minimisation, environmental safety, staff survey results) but corrective action plans were not developed to address these areas.||Ensure corrective action plans are developed where areas for improvements are identified.||PA Low||Reporting Complete||22/10/2019|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||i) Six of nine staff files reviewed failed to evidence completion of their orientation programme (sample expanded to include two staff employed since the last audit). ii) The orientation competency checklist for caregivers and registered nurses has not been differentiated. Both checklists are the same.||i) Ensure evidence is retained of staff completing an orientation programme. ii) Ensure the orientation programme is specific to the new employee’s job role and responsibilities.||PA Low||Reporting Complete||22/10/2019|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||A 2019 education schedule has been documented for the service but has not yet commenced. In-services are scheduled to begin at the end of May 2019. Only five hours of in-service education were provided in 2018 as indicated in the education log book (hazard reporting, infection control, food safety, last days of life, and one attendance record that did not indicate what topics were covered). Caregivers and RNs reported that in-service education has been lacking over the past 18 months and that… (this text has been trimmed due to space limits).||Ensure regular in-service education is provided for staff and that it meets DHB contract requirements. Caregiver staff also need to be made aware of how they can enrol in a Careerforce training programme.||PA Moderate||Reporting Complete||22/10/2019|
|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 daily temperature checks for the medication fridge in the treatment room were not documented.||Ensure regular medication fridge temperature checks are completed daily and documented at least weekly.||PA Low||Reporting Complete||22/10/2019|
|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.||(i) The interRAI assessment and long-term care plan had not been completed within 21-days of admission in one long-term resident file (hospital level of care). (ii) Six-monthly interRAI and care plan evaluation had not been completed in three of the six resident files (hospital level of care).||(i) Ensure the interRAI assessment is completed within 21-days of admission. (ii) Ensure the interRAI assessment and care plan evaluations are completed six-monthly on all long-term residents.||PA Low||Reporting Complete||22/10/2019|
|All buildings, plant, and equipment comply with legislation.||Hot water temperatures are not regularly monitored and recorded.||Ensure hot water temperatures are monitored and documented regularly.||PA Low||Reporting Complete||22/10/2019|
|An appropriate 'call system' is available to summon assistance when required.||(i) The call system is not working properly both with the main server and with the staff pagers. This has been identified as an issue related to Wi-Fi access and a new system has been ordered. (ii) Three of four families and two of six residents interviewed stated that call bells were not answered in a timely manner. A call bell report was reviewed for ten rooms over a period of 10 days. Call bell response times exceeded 10 minutes in 29 instances of residents using their call bell. … (this text has been trimmed due to space limits).||(i) Ensure an effective call system is in place to allow staff to answer call bells in a timely manner. (ii) Ensure call bells are promptly answered.||PA Moderate||Reporting Complete||22/10/2019|
|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).||(i) One resident was being restrained in a lazy-boy chair with the control for the lazy boy chair placed out of his reach to prevent him from lowering the leg rest and trying to get out of the chair. This resident has not been assessed for restraint use. (ii) One enabler (bedrails) was actually a restraint due to the resident being unable to voluntarily consent to the use of the bedrails. All documentation in the resident’s file was around use of an enabler.||(i) Ensure restraint procedures are followed for all residents whose freedom of movement is limited to keep them safe. (ii) Ensure all enablers are voluntary, otherwise should be managed as restraint.||PA Moderate||Reporting Complete||22/10/2019|
|Services conduct comprehensive reviews regularly, of all restraint practice in order to determine: (a) The extent of restraint use and any trends; (b) The organisation's progress in reducing restraint; (c) Adverse outcomes; (d) Service provider compliance with policies and procedures; (e) Whether the approved restraint is necessary, safe, of an appropriate duration, and appropriate in light of consumer and service provider feedback, and current accepted practice; (f) If individual plans of care/… (this text has been trimmed due to space limits).||There has been no evidence of the review of the restraint minimisation programme to identify trends, adherence to the restraint policies and procedures, and staff education.||Ensure the restraint programme is reviewed regularly.||PA Low||Reporting Complete||13/11/2019|
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: 13 May 2019
Audit type:Certification Audit
- St Joseph's Home & Hospital - May 2019 (docx, 48.05 KB)
- St Joseph's Home & Hospital - May 2019 (pdf, 186.5 KB)
Audit type:Surveillance Audit
- St Joseph's Home & Hospital - Dec 2017 (docx, 32.39 KB)
- St Joseph's Home & Hospital - Dec 2017 (pdf, 130.47 KB)
Audit type:Certification Audit
- St Joseph's Home & Hospital - May 2016 (docx, 40.49 KB)
- St Joseph's Home & Hospital - May 2016 (pdf, 160.83 KB)
Audit type:Surveillance Audit
- St Joseph's Home & Hospital - Nov 2014 (docx, 50.05 KB)
- St Joseph's Home & Hospital - Nov 2014 (pdf, 145.36 KB)
Audit type:Certification Audit