St Joseph's Lifecare

Profile & contact details

Premises details
Premises nameSt Joseph's Lifecare
Address 237 Fergusson Drive Heretaunga Upper Hutt 5018
Total beds89
Service typesDementia care, Rest home care, Geriatric, Medical
Certification/licence details
Certification/licence nameHeritage Lifecare Limited - St Joseph's Lifecare
Current auditorBSI Group New Zealand Ltd
End date of current certificate/licence31 March 2027
Certification period36 months
Provider details
Provider nameHeritage Lifecare Limited
Street address 16 Johnsonville Road Johnsonville Wellington 6037
Post addressPO Box 13223 Johnsonville Wellington 6440

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: 29 January 2024

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
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.i). Maintenance requests are not signed off or dealt with in a timely manner. ii). Identified rooms in the facility repeatedly evidence water temperatures of between 45 and 51 degrees in identified rooms. i). Ensure maintenance requests are addressed in a timely manner. ii) Ensure water temperatures in resident rooms are below 45 degrees. PA LowIn 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.Timeframes related to contractual requirements were not always completed for the files reviewed including: i). Two of ten (one rest home and one hospital) resident files did not evidence an initial GP visit within contractual requirements. ii). Three of nine (one hospital, one rest home and one dementia) initial interRAI assessments were not completed within 21 days of admission. iii). Seven of nine (two dementia, two rest home, three hospital) files reviewed did not evidence an initial long-ter… (this text has been trimmed due to space limits).i). Ensure the GP completes an initial visit within five days of admission. ii-v) Ensure initial and repeat interRAI assessments, initial long-term care plans, and activities care plans are documented within required timeframes. vi). Ensure interRAI assessments occur prior to care planning and care plan evaluations. PA ModerateIn Progress
A medication management system shall be implemented appropriate to the scope of the service.i). Room temperatures in each of the three medication rooms evidenced recent occasions where the temperature was above 25 degrees. ii). Room and fridge temperatures were not consistently monitored in the dementia unit. iii). Eye drops required to be stored in the fridge were stored on medication room shelves in the rest home. iv). Two eye drops in dementia unit (expired) were still in use. v). Controlled medication registers in rest home and hospital evidence on occasion, entries with one sign… (this text has been trimmed due to space limits).i). Ensure medication room temperatures are maintained below 25 degrees. ii). Ensure fridge and room temperatures are consistently monitored as per policy and legislation. iii-iv).) Ensure eye drops are stored and discarded as per manufacturer’s instructions. v). Ensure controlled drug administration evidence signatures of two staff. Vi). Ensure paper-based medication charts include photos, and allergies and do not include transcribing. PA ModerateIn 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).i). One rest home resident with a spouse in a neighbouring room did not have an intimacy plan documented for a married couple. ii). One rest home resident did not have interventions documented to manage specific mobility requirements, non-pharmaceutical pain management, or management of an indwelling catheter. iii). Two residents (one hospital and one rest home) with diabetes did not include signs and symptoms of hypoglycaemia or hyperglycaemia and one of these did not include reportable ranges… (this text has been trimmed due to space limits).i). – vi). Ensure all care plan interventions are current, individualised and reflect the assessed needs of residents. PA ModerateIn Progress
I shall have the right to make an informed choice and give informed consent.Seven of ten files reviewed did not have a general consent form. Ensure signed general consent forms are available on each file. PA LowIn 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). Inconsistent monitoring (paper and worklogs) of neurological observations was identified in four of six incident reports reviewed related to unwitnessed falls. ii). Restraint monitoring had not been completed as scheduled for one of three residents using restraint. iii). Repositioning charts were not completed as scheduled for two of two resident files reviewed. iv). Food and fluid intake were not fully documented for a dementia resident. v). Behaviour charts following absconding and physic… (this text has been trimmed due to space limits).i-v). Ensure monitoring occurs as scheduled. PA ModerateIn Progress
My complaint shall be addressed and resolved in accordance with the Code of Health and Disability Services Consumers’ Rights.Four complaints investigated and signed off did not evidence that the resolution letters provide other avenues of raising the complaint should the complainant not be satisfied. Ensure complaints process links with the advocacy service. PA LowIn 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: 29 January 2024

Audit type:Certification Audit

Audit date: 03 February 2023

Audit type:Provisional Audit

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