Te Aroha & District Community Hospital

Profile & contact details

Premises details
Premises nameTe Aroha & District Community Hospital
Address 72 Stanley Avenue Te Aroha 3320
Total beds46
Service typesGeriatric, Medical, Rest home care
Certification/licence details
Certification/licence nameTe Aroha & District Health Services Charitable Trust - Te Aroha & District Community Hospital
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence12 July 2021
Certification period36 months
Provider details
Provider nameTe Aroha and District Health Services Charitable Trust
Street address 72 Stanley Avenue Te Aroha 3320
Post address

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: 14 November 2019

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.One resident identified as requiring hospital level of care is being cared for in a dedicated rest home building. The service has not obtained a dispensation from HealthCERT. Ensure a dispensation from HealthCERT is obtained for the resident requiring hospital level of care in a rest home environment. PA LowReporting Complete30/04/2020
A process to measure achievement against the quality and risk management plan is implemented.Not all audits for 2017 and 2018 have been completed as scheduled. Since the draft report the provider has advised these are now up to date. Ensure that internal audits are completed as per schedule and reported. PA LowReporting Complete29/01/2019
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.Action plans have not been documented for all internal audits where a shortfall has been identified, examples include the restraint audit for February 2018, and medication audit for September 2017. Ensure that shortfalls identified through internal audit have an action plan documented and followed up. PA LowReporting Complete29/01/2019
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) There has been no medication reconciliation for the respite resident on admission. There is no medication drug chart or signed GP order for staff to administer from. Medications are being administered to the resident from medication labels on medication bottles. (ii) Five out of fourteen ‘as required’ medications do not include indications for use. (i) Ensure all respite residents have a written prescription. (ii) Ensure all ‘as required’ medications have indications for use charted. PA ModerateReporting Complete29/01/2019
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.(i)One hospital PACC resident has no current care plan in place (has been a resident five and a half months). (ii) One rest home resident who has commenced wandering had no interventions to manage the risks related to wandering in the care plan. (iii) One resident’s care plan has been written before the completion of the interRAI assessment and had not been updated to reflect the interRAI assessment. (iv) The care plan of one resident with restraint does not include interventions to support rest… (this text has been trimmed due to space limits).(i)Ensure all PACC residents have a documented care plan. (ii) Ensure all residents have interventions documented to around assessed needs and risks. (iii) Ensure that care plan interventions reflect assessed needs identified through interRAI assessment. (v) –(vi) Ensure restraint is documented in the care plan and enablers are named. PA ModerateReporting Complete29/01/2019
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).Two-hourly monitoring of restraint use was not reflected on the restraint monitoring forms for the two residents’ files reviewed. Ensure monitoring forms reflect documented evidence of restraint use being monitored. PA LowReporting Complete29/01/2019
An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.Written complaints (and potentially verbal complaints) are not documented on the complaints register. Complete a register of complaints that includes all complaints, dates, and actions taken. PA LowReporting Complete30/04/2020
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.(i) One hospital and one rest home resident did not have an interRAI assessment and long-term care plan completed within 21 days of admission. (ii) Two hospital and two rest home residents did not have routine six monthly interRAI assessments and long-term care plans evaluations were not completed on time. (i) Ensure an interRAI assessment and long-term care plan is completed within 21 days of admission. (ii) Ensure routine six-monthly interRAI assessments and long-term care plan evaluations are completed on all long-term residents. PA LowReporting Complete30/04/2020
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.(i) Two rest home residents with identified weight loss did not have sufficient interventions in place in the care plan. (ii) One rest home resident with an history of recurrent urinary tract infections did not have documented measures in place to reduce the risk of infection. (iii) One rest home resident with challenging behaviours did not have interventions in place identifying triggers of challenging behaviours, management strategies and behaviour monitoring charts (i) Ensure interventions are in place for residents with identified weight loss. (ii) Ensure interventions in place for identifying urinary tract infections and minimising risk for residents that have recurrent urinary tract infections. (iii) Ensure residents with challenging behaviours have a behaviour plan in place that includes triggers, strategies to de-escalate and behaviour monitoring charts. PA ModerateReporting Complete30/04/2020
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.Four of four residents who had an unwitnessed fall in October or November 2019 did not have neurological observations taken. Ensure that neurological observations are taken when there is a head injury following a fall or there is an unwitnessed fall. PA ModerateReporting Complete30/04/2020
The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.Rest home residents did not have regular registered nurse evaluations and input documented in the progress notes. Ensure that the rest home residents have regularly documented registered nurse evaluations and input in the progress notes. PA LowReporting Complete30/04/2020
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.(i). There is a minimal documentation of analysis of clinical data with evidence of improvements to service delivery as a result of the discussion. (ii). A satisfaction survey for residents and families in the hospital and rest home has not been completed adequately to determine levels of satisfaction with the service (i). Document evidence of analysis of data with corrective action planning and documentation of resolution of issues. (ii). Complete a satisfaction survey, collate results and ensure that residents and families are informed of the results PA ModerateReporting Complete05/06/2020

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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