St Margaret's Hospital and Rest Home
Profile & contact details
|Premises name||St Margaret's Hospital and Rest Home|
|Address||52 Beach Road Te Atatu Peninsula Auckland 0610|
|Service types||Physical, Dementia care, Rest home care, Geriatric, Medical|
|Certification/licence name||CHT Healthcare Trust - St Margaret's Hospital and Rest Home|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||11 December 2019|
|Certification period||36 months|
|Provider name||CHT Healthcare Trust|
|Street address||97 Great South Rd Market Road Auckland 1543|
|Post address||PO Box 74341 Market Road Auckland 1543|
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: 05 June 2018
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Six of ten resident files (three hospital and three from the dementia unit) had identified issues that were not documented in the long-term care plan. One resident (hospital level) did not have a short-term care plan developed on return from hospital.||Ensure all identified needs are documented on a care plan.||PA Low||Reporting Complete||12/04/2017|
|Each episode of restraint is evaluated in collaboration with the consumer and shall consider: (a) Future options to avoid the use of restraint; (b) Whether the consumer's service delivery plan (or crisis plan) was followed; (c) Any review or modification required to the consumer's service delivery plan (or crisis plan); (d) Whether the desired outcome was achieved; (e) Whether the restraint was the least restrictive option to achieve the desired outcome; (f) The duration of the restraint episode… (this text has been trimmed due to space limits).||Restraint use is scheduled to be evaluated six-monthly (at a minimum). Two residents’ files reviewed indicated that the evaluations for both residents were last completed in December 2015.||Ensure the use of restraint is evaluated as per CHT policy.||PA Low||Reporting Complete||12/04/2017|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i) Thirteen wounds did not have a comprehensive assessment and four wounds did not have a documented wound management plan. (ii) Two turning charts (hospital level) had occasions where they had not been completed. (iii) One resident (rest home level) requiring weekly blood pressure readings had not had these documented for the previous two weeks.||(i) Ensure every wound has a comprehensive assessment and a wound management plan. (ii) Ensure that turning charts are documented when completed. (iii) Ensure that the GPs instructions are followed.||PA Moderate||Reporting Complete||10/07/2017|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||(i)Two of two hospital care plans did not include all interventions to safety guide resident care. (a) One file did not document interventions around moving and handling, management of weight loss, the need for two hourly turns, and management of behaviours that challenge. (b) One file did not document interventions around pain management and pressure injury prevention, and included contradictory advice regarding moving and handling. (ii) One of two rest home care plans did not include interve… (this text has been trimmed due to space limits).||(i)-(iii) Ensure that care plans are individualised to resident needs and include all interventions to safely guide care. (iv)- (v) Ensure that short-term/acute changes in care have a documented short-term care plan and documented resolution or the long-term care plan updated.||PA Moderate||Reporting Complete||24/10/2018|
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: 05 June 2018
Audit type:Surveillance Audit
- St Margaret's Hospital and Rest Home - Jun 2018 (docx, 33.71 KB)
- St Margaret's Hospital and Rest Home - Jun 2018 (pdf, 134.38 KB)
Audit type:Certification Audit
- St Margaret's Hospital and Rest Home - Sep 2016 (docx, 44.04 KB)
- St Margaret's Hospital and Rest Home - Sep 2016 (pdf, 175.67 KB)
Audit type:Surveillance Audit
- St Margaret's Hospital and Rest Home - Nov 2015 (docx, 35.49 KB)
- St Margaret's Hospital and Rest Home - Nov 2015 (pdf, 140.25 KB)
Audit type:Certification Audit