Tairua Residential Care
Profile & contact details
|Premises name||Tairua Residential Care|
|Address||7 Tui Terrace Tairua 3508|
|Service types||Medical, Rest home care, Geriatric|
|Certification/licence name||Tairua Residential Care Limited - Tairua Residential Care|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||27 April 2018|
|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: 02 March 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|In assessing whether restraint will be used, appropriate factors are taken into consideration by a suitably skilled service provider. This shall include but is not limited to: (a) Any risks related to the use of restraint; (b) Any underlying causes for the relevant behaviour or condition if known; (c) Existing advance directives the consumer may have made; (d) Whether the consumer has been restrained in the past and, if so, an evaluation of these episodes; (e) Any history of trauma or abuse, whi… (this text has been trimmed due to space limits).||Restraint assessments were missing in two of three residents where bedrails were being used as a restraint. The RN staff used a restraint evaluation form for the third resident using restraint.||Ensure that a restraint assessment process is completed that covers all aspects of the criterion ((a) – (h)) before any restraint is put into place.||PA Moderate||Reporting Complete||10/06/2016|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Adverse event data is collected with numbers communicated to staff in staff meetings but there is no evidence of the analysis of this data. Staff were not informed of internal audit results in 10 of 12 monthly staff meetings for 2015, evidenced in the monthly staff meeting minutes.||Ensure adverse event data is analysed and internal audit results are routinely communicated to staff.||PA Low||Reporting Complete||10/04/2017|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Internal audit results are completed and include a summary that documents findings and recommendations. Missing is evidence of corrective action plans where results reflect the need for improvements and a process for evaluating corrective action plans.||Ensure corrective action plans are routinely developed where indicated and there are processes in place to evaluate the effectiveness of corrective actions that are developed.||PA Low||Reporting Complete||10/04/2017|
|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.||(i) One resident had paracetamol administered as a standing order nine times over a week before the GP was informed. (ii) Nine of fourteen medication charts reviewed reflected medications were not recorded as given as prescribed.||(i) Ensure that GP is informed for all standing order medications given for over 24 hours as per facility policy and (ii) ensure that all medications are given as prescribed.||PA Moderate||Reporting Complete||10/04/2017|
|The facilitation of safe self-administration of medicines by consumers where appropriate.||i) Five of five self-medicating residents did not have a current assessment of their competency and ii) there was no system in place for RN checking that residents had administered their medications each shift.||i) Ensure that all self-medicating residents have a competency reassessment at least every three months and ii) ensure that the RN checks that the resident has taken their medication each shift.||PA Moderate||Reporting Complete||10/04/2017|
|The needs, outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning.||i) Three of four residents admitted since 1 July 2015 did not have an interRAI assessment completed within 21 days of admission and ii) one resident who was reassessed as requiring hospital level of care whilst in public hospital did not have an interRAI assessment completed on their return to the facility.||i) Ensure that all new admissions have an interRAI assessment completed within 21 days of admission and ii) ensure that all residents with a significant change to their health status have an interRAI assessment completed.||PA Low||Reporting Complete||10/04/2017|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||Wound assessments and comprehensive wound management plans were not in place in 10 of 10 wounds reviewed. Four of four pressure injuries did not have a wound assessment or comprehensive wound management plan.||i) Ensure all pressure injuries and wounds have a wound assessment and comprehensive wound management plan.||PA Moderate||Reporting Complete||10/04/2017|
|Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome.||Two residents with significant changes in their health needs have not had their care plans updated.||Ensure that residents care plans are updated to reflect changes in their health needs||PA Moderate||Reporting Complete||10/04/2017|
|All buildings, plant, and equipment comply with legislation.||Medical and electrical equipment has not been serviced or calibrated within the last 12 months.||Ensure all medical and electrical equipment is serviced and/or calibrated every 12 months||PA Low||Reporting Complete||10/04/2017|
|Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.||Ensure a minimum of one staff trained in CPR and first aid is available in the van when taking residents on outings.||Ensure staff who take residents on outings hold a current first aid/CPR certificate.||PA Low||Reporting Complete||10/04/2017|
|Each episode of restraint is documented in sufficient detail to provide an accurate account of the indication for use, intervention, duration, its outcome, and shall include but is not limited to: (a) Details of the reasons for initiating the restraint, including the desired outcome; (b) Details of alternative interventions (including de-escalation techniques where applicable) that were attempted or considered prior to the use of restraint; (c) Details of any advocacy/support offered, provided o… (this text has been trimmed due to space limits).||Monitoring each episode of restraint use was not consistently evident in the three resident’s files reviewed.||Ensure residents are monitored while restraint is in use, and that this is documented in the resident’s files.||PA Low||Reporting Complete||10/04/2017|
|Where progress is different from expected, the service responds by initiating changes to the service delivery plan.||Two of five care plans had not been updated when progress differed from expectations. The care plan of the resident with the pressure injury had not been updated to reflect the changes to service delivery, and the care plan of one rest home resident was not updated following a skin tear and there is no wound documentation on record regarding the skin tear. This was a finding at the previous certification audit.||Ensure changes in health status of residents are recorded in their care plans.||PA Moderate||In Progress|
|The needs, outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning.||One of two people admitted for carer support did not have any documentation related to assessment and service delivery and there is no policy to guide practice.||Develop and implement policy on people receiving respite services.||PA Low||In Progress|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||Two residents were required to be turned two hourly for pressure area management (one with a PI and one who has the potential to develop a PI). The practice is for staff to record the turning of residents in the progress notes. This was not occurring consistently by staff on all shifts when the patient was in bed.||Ensure the documentation of two hourly turning of residents occurs in progress notes and the procedure is monitored through the internal audit programme.||PA Low||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.||There was no incident form completed for a resident with a pressure injury; and there were no incident forms completed for a resident who exhibited challenging behaviours over a period of two months prior to a serious incident occurring.||Ensure that incident and accident forms are completed for adverse events.||PA Moderate||Reporting Complete||10/05/2017|
|The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.||A Section 31 notice had not been completed for a resident involved in the serious incident of challenging behaviour which involved the Police being called and the resident being sectioned under the Mental Health Act and transferred to a secure facility at the District Health Board. The Section 31 notice was completed on the day of audit and a copy provided to the Ministry of Health and the District Health Board.||Ensure that all obligations for essential reporting occur in a timely manner.||PA Low||Reporting Complete||10/05/2017|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Corrective actions developed have not been evaluated, followed up and signed off for all internal audits and the resident/relative satisfaction survey and there is no internal audit tool for auditing pressure injuries. This was a finding at the previous certification audit.||Ensure there are processes in place to evaluate, follow up and sign off corrective actions that are developed for internal audits and the resident/relative satisfaction survey and ensure there is an internal audit tool for pressure injury management.||PA Low||Reporting Complete||20/09/2017|
|The facilitation of safe self-administration of medicines by consumers where appropriate.||The medicine orders for all four residents did not identify the medicines that each resident was self-administering; there was no evidence in the administration signing sheet that staff had checked these residents had taken their medications as prescribed each shift; and three of four residents did not have access to secure storage for the medicines they were self-administering. The management of residents self-administering medicines was a finding at the previous certification audit. … (this text has been trimmed due to space limits).||Ensure the documentation of residents who self-administer medicines complies with current guidelines.||PA Moderate||Reporting Complete||20/09/2017|
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: 02 March 2017
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
- Tairua Residential Care - Feb 2016 (docx, 51.27 KB)
- Tairua Residential Care - Feb 2016 (pdf, 172.23 KB)
Audit type:Surveillance Audit
- Tairua Residential Care - Mar 2015 (docx, 33.02 KB)
- Tairua Residential Care - Mar 2015 (pdf, 134.54 KB)
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Provisional Audit