Stokeswood Rest Home & Hospital

Profile & contact details

Premises details
Premises nameStokeswood Rest Home & Hospital
Address 18 Glen Road Stokes Valley Lower Hutt 5019
Websitewww.bupa.co.nz/care-homes/care-homes/choose-a-care-home/wellington/stokeswood-rest-home-and-hospital/
Total beds87
Service typesDementia care, Rest home care, Geriatric, Medical
Certification/licence details
Certification/licence nameBupa Care Services NZ Limited - Stokeswood Rest Home & Hospital
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence15 May 2021
Certification period36 months
Provider details
Provider nameBupa Care Services NZ Limited
Street addressLevel 2 109 Carlton Grove Road Newmarket Auckland 1023
Post addressPO Box 113054 Newmarket Auckland 1149
Websitewww.bupa.co.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: 29 August 2019

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
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.(i) A review of controlled drugs (CDs) administered in the dementia community/unit identified examples where CDs were borrowed from other residents when stock was not on hand. (ii) The respite (rest home) resident had two faxed medication charts. It was unclear which was current. A discontinued medication by the GP was signed as given for the next two days following it being discontinued. The computerised medication signing chart listed medications in the robotic pack that were being signed… (this text has been trimmed due to space limits).(i) Ensure CDs are administered from either the stock hospital supply or the residents own supply; (ii) Ensure there is only one medication chart in place per resident and signing sheets reflect what is administered; (iii) Ensure BSLs identified as high or low are followed up as per policy PA ModerateReporting Complete03/10/2018
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 in the care plans reviewed. (i) Two of three dementia level files had interventions updated in the care plan, but obsolete interventions were not signed out as not relevant; (ii) In one of three hospital files, the interventions around restraint and thickened fluids did not align in the care summary and LTCP. (iii) In one of three rest home files, interventions in the mobility section of the care plan had not been updated to reflect the resident’s statu… (this text has been trimmed due to space limits).Ensure care plans reflect current assessed needs and only include interventions to support current needs. PA LowReporting Complete03/10/2018
Consumers are provided with safe and accessible external areas that meet their needs.There is a large outdoor area off the dementia community/unit that extends around the dementia unit. There are a number of external doors from the dementia community/unit to access the secure outdoor area, however (with the exception of one door) these are kept locked due to some of the outdoor paths and areas being uneven. Advised that residents in that outdoor area are supervised to minimise the risk of falls. There is a plan in place to further landscape this secure outdoor area and remove… (this text has been trimmed due to space limits).Ensure the outdoor secure area off the dementia community/unit is fully accessible and uneven services and hazards removed. PA LowReporting Complete18/12/2018
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.There was no documented evidence of eight hours annual training being completed for all staff in 2017. Attendance at core in-service training has been low. For example, code of rights – 17 of 88 staff, abuse and neglect – 17 of 88 staff and cultural safety – 7 of 88 staff. Ensure that staff complete at least 8-hours annually. Ensure staff that do not attend the in-service programme access training other ways, and this is documented. PA LowReporting Complete19/12/2018
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.(i). Of the thirteen staff working in the dementia unit, six have not completed the dementia standards within timeframes. (ii). End of life training has not been documented as occurring following a Health and Disability complaint. (iii). Four of five staff files documented that annual appraisals were not up to date. (i). Ensure that staff who work in the dementia unit have completed the limited credits dementia training within set timeframes. (ii). Ensure end of life training is provided for staff as directed by the Health and Disability response. (iii). Ensure that staff have a documented annual appraisal. PA ModerateIn Progress
Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.The service has not documented any trial fire evacuations since 2018. Ensure trial evacuations are held six monthly. PA ModerateIn Progress
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.(i). One hospital level care plan had not been personalised to reflect the most common reasons and interventions for the resident’s high falls and there was no reference to the sacral abrasion in the long-term care plan (or a short-term care plan). (ii). One hospital level care plan did not include the use of a leg brace (an arm sling was identified). There were no instructions for how or when to apply the leg brace or arm sling. Ensure care plans reflect interventions to support current assessed needs. PA ModerateIn Progress
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.(i). Internal audits and complaints are not documented as reported to meetings. (ii). Incident and accident results are reported to RN meetings, but not the staff or quality meetings. (iii). Staff meetings have been documented for February and May only (rather than one to two monthly as scheduled). (iv). The quality meeting viewed for January to August 2019 documented large sections of copied minutes with the meeting minutes for March being an entire copy of January’s meeting. (i)-(iv) Ensure that meetings are documented as scheduled and that meeting minutes reflect communication and discussion of up-to-date quality results. PA LowIn Progress
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.(i) One paper-based chart (rest home) had no indication for use for ‘as required’ medication. (ii) One paper-based chart (dementia); the signing sheet and the blister pack did not match the medication chart. (i) Ensure that as needed medication includes indications for use; (ii) Ensure medication charts in place reflect what is administered. PA ModerateIn 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. 

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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