Tairua Residential Care
Profile & contact details
|Premises name||Tairua Residential Care|
|Address||7 Tui Terrace Tairua 3508|
|Service types||Rest home care, Geriatric, Medical|
|Certification/licence name||Tairua Residential Care Limited - Tairua Residential Care|
|Current auditor||HealthShare Limited|
|End date of current certificate/licence||27 April 2023|
|Certification period||24 months|
|Provider name||Tairua Residential Care Limited|
|Street address||7 Tui Terrace Tairua 3508|
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: 10 February 2021
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|A process to measure achievement against the quality and risk management plan is implemented.||Not all audits have been completed as per schedule.||Ensure that audits are completed so that service delivery can be monitored as per schedule||PA Low||In Progress|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Resolution of issues when identified in corrective action plans is not documented.||Document evidence of resolution of issues when identified in corrective action plans.||PA Moderate||In Progress|
|Service providers responsible for medicine management are competent to perform the function for each stage they manage.||Three of three caregivers interviewed who were involved in checking and signing for medication (including controlled drugs) had not completed a medication competency.||Ensure all staff involved in the medication administration process are competent to perform the stage in which they are involved.||PA Moderate||In Progress|
|The service is able to demonstrate that written consent is obtained where required.||Four of seven resident records reviewed did not have informed consent forms completed.||Ensure that residents or family complete a consent form on entry to the service.||PA Low||In Progress|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||(i). There were no records of food temperatures being monitored and recorded and a resident fridge was outside the acceptable temperature range (between 8°C and 10°C) daily for over a month with no corrective actions. (ii). A food control plan has not been verified.||(i). Ensure food temperatures are monitored and documented and corrective actions are undertaken to maintain food safety. (ii). Ensure that a food control plan is verified.||PA Moderate||In Progress|
|Where an episode of restraint is ongoing the time intervals between evaluation processes should be determined by the nature and risk of the restraint being used and the needs of the consumers and/or family/whānau.||(i). Frequency of monitoring of restraint is not documented in the care plan when restraint is used or for each restraint used if more than one restraint is in use for an individual resident. (ii). Documentation of the time the restraint was put on and taken off and evidence of times monitored is not recorded adequately in the resident record.||(i). Document frequency of monitoring of restraint in the care plan. (ii) Document records of monitoring of the use of restraint for individual devices and residents including time on and off and time the restraint was checked.||PA Moderate||In Progress|
|Service providers follow a documented process for the safe and appropriate storage and disposal of waste, infectious or hazardous substances that complies with current legislation and territorial authority requirements.||Chemicals are stored in an open, non-lockable cupboard. A corrective action plan to remedy this was commenced on day of audit.||Ensure all chemicals are stored safely in a manner not accessible to residents and visitors.||PA Low||In Progress|
|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 have not been reviewed at frequent intervals or to reflect changes in legislation.||Review policies as per schedule and to reflect changes in legislation.||PA Moderate||In Progress|
|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.||(i). Eighteen of 20 incident forms (December 2020 -January 2021) reviewed did not show evidence that the nurse manager had reviewed the incident, or evidence of investigations and remedial actions being implemented as required. (ii). Five of eight unwitnessed falls did not have neurological observations taken.||(i). Ensure the incidents are reviewed and close out incidents documented on TIS forms in a timely manner. Ensure documentation reflects that investigations and remedial actions have been implemented as required. (ii). Ensure neurological observations are completed where the resident has hit their head or potentially hit their head.||PA Moderate||In Progress|
|Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer.||Three of seven files reviewed did not have an initial interRAI assessment completed, and one of seven files reviewed did not have the initial interRAI completed within the required timeframe of 21 days of admission. Ten specialised assessments were not completed in a timely manner as per policy.||Ensure all resident assessments, including interRAI and specialised assessments, are completed within the required timeframes.||PA Moderate||In Progress|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Interventions to manage identified care needs were not well documented. Example: (i) De-escalation techniques/interventions to manage behaviours that challenge were not documented for one rest home and one hospital level care resident; (ii) One hospital resident with sustained weight loss did not have interventions to reflect increased frequency of weight monitoring, nutritional supplementation or dietitian input; (iii) One hospital level resident had pain and continence issues triggered in the … (this text has been trimmed due to space limits).||Ensure that care plans reflect resident need and provide care interventions to manage care.||PA Moderate||In Progress|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||There is little discussion of data tabled at the staff meeting.||Ensure that meeting minutes reflect discussion of clinical and other quality data including (but not limited to) restraint and complaints when this is tabled.||PA Low||In Progress|
|The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code.||The complainants have not been provided with written confirmation of the complaint or written documentation of progress of the investigations as per the complaints policy.||Provide written confirmation that the complaint has been received and progress as per the investigation to the complainants as per the complaints policy.||PA Moderate||Reporting Complete||27/04/2022|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||A complaints register is not maintained.||Maintain an up-to-date complaint register.||PA Low||Reporting Complete||27/04/2022|
|Consumers have a right to full and frank information and open disclosure from service providers.||Seven incident forms of the 20 reviewed did not include evidence that family had been informed and the progress notes checked did not confirm that family had been informed.||Ensure that relatives are informed of any incident or accident as per policy.||PA Low||Reporting Complete||27/04/2022|
|Advance directives that are made available to service providers are acted on where valid.||Six of seven resident records did not include an advance directive.||Ensure that residents are asked if they wish to sign an advance directive.||PA Low||Reporting Complete||27/04/2022|
|Entry criteria, assessment, and entry screening processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies.||Four of seven resident files admitted between June and December 2020 did not have admission agreements completed and signed by service, resident or family.||Ensure admission agreements are fully completed and signed by the service, resident and/or family as per policy.||PA Low||Reporting Complete||27/04/2022|
|The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.||Three of the seven long-term care plans reviewed showed no evidence of resident and family/whānau involvement in the care plan process||Ensure there is documented evidence that residents and/or family are involved in the care planning process.||PA Low||Reporting Complete||27/04/2022|
|Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.||(i). Four of four medication charts reviewed did not contain the required documented indications/instructions re crushed medications. (ii). Three monthly GP reviews could not be evidenced for thirteen of fourteen medication charts reviewed||(i). Ensure all resident medication charts are fully completed with indications/instructions re crushed medications. (ii). Ensure all medication charts are reviewed at least three monthly and that this is clearly evidenced||PA Moderate||Reporting Complete||27/04/2022|
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.
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 reportsAudit date: 10 February 2021
Audit type:Certification Audit
- Tairua Residential Care - Feb 2021 (docx, 50.61 KB)
- Tairua Residential Care - Feb 2021 (pdf, 197.06 KB)
Audit type:Surveillance Audit
- Tairua Residential Care - Dec 2019 (docx, 35.12 KB)
- Tairua Residential Care - Dec 2019 (pdf, 137.03 KB)
Audit type:Certification Audit
- Tairua Residential Care - Feb 2018 (docx, 44.58 KB)
- Tairua Residential Care - Feb 2018 (pdf, 173.72 KB)
Audit type:Surveillance Audit
- Tairua Residential Care - Mar 2017 (docx, 38.92 KB)
- Tairua Residential Care - Mar 2017 (pdf, 134.22 KB)
Audit type:Certification Audit