Summerville Rest Home
Profile & contact details
|Premises name||Summerville Rest Home|
|Address||411 Frederick Street Mahora Hastings 4120|
|Service types||Rest home care|
|Certification/licence name||Sunflower Field Trading NZ Limited - Summerville Rest Home|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||09 December 2018|
|Certification period||24 months|
|Provider name||Sunflower Field Trading NZ Limited|
|Street address||411 Frederick Street Mahora Hastings 4120|
|Post address||19A Knightsbridge Drive Forrest Hill Auckland 0620|
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: 25 October 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|The facilitation of safe self-administration of medicines by consumers where appropriate.||One self-administering resident did not have the medication competency reviewed three monthly by the GP.||Ensure the three monthly GP reviews include the self-medication competency if the resident self-medicates medications.||PA Low||Reporting Complete||22/12/2016|
|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 resident on oxygen (noting that the respiratory clinic notes and the GP notes both refer to the use of oxygen) did not have this charted on the medication chart and one resident on Buscopan as needed, (noting this was prescribed on an earlier medication chart and was being dispensed by the pharmacy) did not have this medication charted on the current medication chart; and ii) a caregiver was observed administering an ‘as needed’ medication without checking the medication chart, or asking… (this text has been trimmed due to space limits).||i) Ensure that all medication is prescribed; and ii) ensure that all staff follow the medication policies and procedures, including RN assessment prior to the administration of PRN analgesia.||PA Moderate||Reporting Complete||22/12/2016|
|The organisation has a quality and risk management system which is understood and implemented by service providers.||The service does not have a current annual business/quality plan for 2016 in place, including annual goals, objectives, action plans, responsibilities and date/timeframes||Ensure that an annual business/quality plan is documented and implemented.||PA Low||Reporting Complete||07/04/2017|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||The evaluation of wounds did not include information such as size, depth and exudate.||Ensure the evaluation of wounds is comprehensive to allow comparison and to measure improvement.||PA Low||Reporting Complete||07/04/2017|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||For two of the resident files reviewed the activities plan was not reflective of the activities assessment and the InterRAI social needs assessment.||Ensure that activities plans are individualised to the resident need and relevant assessments.||PA Low||Reporting Complete||07/04/2017|
|The service develops and implements policies and procedures that are aligned with current good practice and service delivery, meet the requirements of legislation, and are reviewed at regular intervals as defined by policy.||Policies and procedures reviewed which do not provide in-depth guidance for staff include the abuse/neglect, sexuality/intimacy, spirituality, privacy/dignity, informed consent, cultural safety, open disclosure, admission processes, incident reporting and staffing rationale policies.||Ensure that all policies are reviewed to meet the requirements of the relevant Health and Disability Services Standards 2008.||PA Low||Reporting Complete||21/06/2017|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Two resident files for residents with behaviour that challenges had the behaviour documented in the care plan but no interventions as to how to manage the behaviour.||Ensure that care plans document all resident needs and required management interventions.||PA Low||Reporting Complete||15/09/2017|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||i) Five staff files reviewed did not have signed job descriptions; ii) two files did not have employment contracts; and iii) one staff file reviewed did not evidence completed orientation documentation||i) Ensure all staff files evidence a copy of a signed job description; ii) ensure all staff files evidence a signed employment agreement; and iii) ensure that all staff complete the orientation programme documentation||PA Low||Reporting Complete||15/09/2017|
|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 incident/accident forms were reviewed in total. Ten of twelve incident/accident forms reviewed did not have documented evidence of notification to the next of kin. Three incident/accident forms reviewed were for unwitnessed resident falls with a head injury. There was no documented evidence of neurological observations forms being completed.||Ensure that next of kin are notified of any incident and that neurological observations forms are completed for any resident fall with a head injury.||PA Low||Reporting Complete||12/03/2018|
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: 25 October 2017
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Provisional Audit