Summerset By The Park

Profile & contact details

Premises details
Premises nameSummerset By The Park
Address 7 Flat Bush School Road Flat Bush Auckland 2016
Total beds84
Service typesMedical, Rest home care, Geriatric
Certification/licence details
Certification/licence nameSummerset Care Limited - Summerset By The Park
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence21 April 2019
Certification period24 months
Provider details
Provider nameSummerset Care Limited
Street addressLevel 12, State Insurance Tower 1 Willis Street Wellington Central Wellington 6011
Post addressPO Box 5187 Lambton Quay Wellington 6145

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: 21 March 2017

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate 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) One unstageable pressure injury as identified in photos had not been staged and was not entered on the wound register and there was no evidence of a wound assessment, treatment plan or review documentation. The only intervention was the application of moisturiser. ii) Pain assessment and monitoring had not been reviewed following the development of a stage two sacral pressure injury. i) Ensure that wound assessments, plans and reviews are completed for all wounds and that appropriate wound care is implemented. ii) Ensure that pain assessments and monitoring are implemented as required. PA ModerateReporting Complete29/05/2017
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.Three hospital residents did not have sufficient interventions documented in the care plan to address all identified needs. Ensure that resident care plans include nursing interventions for identified needs. PA ModerateReporting Complete29/05/2017
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.Twelve of twenty accident/incident forms selected for review (November and December 2016) had not been signed off by the clinical manager as closed. The clinical manager confirmed that there is a backlog and that this is an issue that he is currently working on. Ensure adverse events are reviewed by the nurse manager in a timely manner. PA ModerateReporting Complete29/05/2017
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.Seven of sixteen medication charts did not identify indications for use for ‘as required’ medications. Ensure ‘as required’ medications have indications for use documented. PA ModerateReporting Complete29/05/2017
Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.i) Foodstuffs in the fridge, freezer and pantry did not evidence dates of when they were initially opened. ii) Prepared foodstuffs in the fridge (eg, prepared meals) do not evidence initial preparation dates. iii) Dried goods such as herbs, spices, flour etc. did not always evidence expiry dates or decanting dates. Ensure all foodstuffs are dated and stored as per policy. PA LowReporting Complete31/07/2017
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).There is a lack of evidence to indicate that hazards identified on the hazard register are regularly monitored. Ensure hazards are regularly monitored as per the health and safety plan for the organisation. PA LowReporting Complete31/07/2017
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.Evidence to support the implementation of corrective action plans was missing for three of eleven complaints received in 2016 where recommendations had been made. Ensure there is evidence to support the implementation of corrective actions that originate from a complaints investigation. PA LowReporting Complete31/07/2017
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.There are gaps in meeting minutes around the reporting of quality and risk information. Ensure staff are kept informed of quality and risk management information including outcomes and areas identified for improvements. PA LowReporting Complete31/07/2017
An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.Eight of ten complaints that were documented as closed failed to reflect evidence of resolution. Ensure the complaints process includes evidence of resolution (or justification as to why this isn’t possible) before closing the complaint. PA LowReporting Complete31/07/2017
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.(i) One rest home resident required blood glucose recordings three times a day as requested by the GP. However, this was not completed. (ii) Four of seventeen wounds reviewed did not have dressings completed at the frequency documented in the wound management plan. (i) Ensure health professionals instructions are fully implemented; (ii) Ensure wounds are redressed at the frequency documented in the wound management plan. PA ModerateIn Progress
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.The care plan for one rest home resident identified a requirement for daily blood sugar levels, but medical notes documented blood sugar levels were to be taken three times a day. This was not included in the care plan. Ensure the care plans reflect interventions to support all current needs and instructions. PA ModerateIn Progress
Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.(i) The respite resident had not had any documented contact from the activities staff since admission. (ii)The monthly progress notes entries have not been completed for three of four long-term resident files. (iii)The six-monthly review of goals and outcomes have not been reviewed for one of three residents who required it. (iv) The goals and outcomes had been documented for one resident admitted within the last six months, but this was not dated. (i) Ensure all residents are assessed by activities staff within 48 hours. (ii) Ensure monthly diversional therapy progress notes are documented for all residents. (iii) Ensure goals and outcomes are reviewed six-monthly. (iv) Ensure all DT documentation is clearly dated. 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. 

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 reports

Audit date: 21 March 2017

Audit type:Surveillance Audit

Audit date: 26 January 2017

Audit type:Certification Audit

Audit date: 30 October 2015

Audit type:Surveillance Audit

Audit date: 28 January 2014

Audit type:Certification Audit

Audit date: 12 February 2013

Audit type:Surveillance Audit

Audit date: 28 February 2012

Audit type:Certification Audit

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