Te Whare Hauora o Ngati Porou
Profile & contact details
|Premises name||Te Whare Hauora o Ngati Porou|
|Address||4 McKenzie Street Te Puia Springs 4048|
|Service types||Medical, Rest home care, Geriatric, Maternity|
|Certification/licence name||Ngati Porou Hauora Charitable Trust Board - Te Whare Hauora o Ngati Porou|
|Current auditor||The DAA Group Limited|
|End date of current certificate/licence||14 November 2020|
|Certification period||36 months|
|Provider name||Ngati Porou Hauora Charitable Trust Board|
|Street address||4 McKenzie Street RD 1 Tokomaru Bay 4079|
|Post address||PO Box 2 Te Puia Springs 4048|
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: 01 April 2019
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Where required by legislation there is an approved evacuation plan.||Trial evacuations have not been staged in the required times and alternatives to Fire Service supervision not identified or sought.||Provide evidence an evacuation drill has occurred.||PA Low||Reporting Complete||16/01/2018|
|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.||The medicine training records sighted did not evidence that staff responsible for medicine administration had completed medication competencies since the last audit.||Provide evidence of medication competencies being completed annually for all staff who are responsible for medicine administration.||PA Moderate||Reporting Complete||03/04/2018|
|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.||Not all hazardous substances are labelled to allow for easy identification and safe use in line with current hazardous substances regulations and territorial requirements. No staff member holds an approved handler certification.||Ensure a relevant staff member becomes a certified approved handler, then review and make the changes required by current hazardous substances regulations regarding safe and appropriate storage. Provide evidence of this.||PA Low||Reporting Complete||03/09/2018|
|Results of surveillance, conclusions, and specific recommendations to assist in achieving infection reduction and prevention outcomes are acted upon, evaluated, and reported to relevant personnel and management in a timely manner.||There is no infection prevention and control coordinator. The incidence of infections has not been recorded or reviewed to enable surveillance processes to be undertaken for infection prevention and control purposes. The incidence of infections is not being recorded or reviewed to enable surveillance processes to be undertaken for infection prevention and control purposes.||A suitably trained and qualified infection control coordinator is appointed and surveillance of the incidence of infections is undertaken in accordance with the directions for these processes as described within the organisation’s infection prevention and control manual. Ensure the surveillance reflects all infections reported and that feedback can be given to staff to act on or to prevent infections in a timely manner.||PA Low||In Progress|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||A basic activities programme is developed and implemented which is flexible and incorporates some activities of interest to the current patients. However, there is no evidence of a social assessment being completed when a new patient is admitted to ensure activities are planned to develop and maintain skills, resources and interests that are meaningful to the individual patient. No attendance records are maintained. No input from a diversional therapist was able to be evidenced.||A social assessment is performed on admission to ensure the interests, background and hobbies of the individual patient is obtained and considered when developing the activities programme and the individual plan for each patient to meet their recreational needs. The programme requires input from a diversional or occupational therapist. Attendance/participation, while not compulsory, is to be recorded as per the service contract with the DHB.||PA Low||In Progress|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||The midwife who is employed by the organisation has significantly increased her caseload. While this is an asset to the service, it has the potential to negatively impact on patient safety and wellbeing. There is not currently a designated clinical manager responsible for hospital level aged care services, as required by the ARRC Agreement.||A clinical manager is appointed to meet contractual requirements. Maternity service staffing levels are improved to ensure the safety of services delivered.||PA Moderate||In Progress|
|Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.||The nutritional needs of patients are effectively met. All special diets are catered for. The service is covered by an experienced cook and kitchen staff. The four weekly summer /winter menu plans have not been reviewed by a registered dietitian for three years.||Ensure the menu plans for the service have been reviewed by a registered dietitian in the required timeframe as per the service contract with the DHB.||PA Low||Reporting Complete||05/08/2019|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||There is not currently a system that enables managers to easily know what training a staff person has or has not completed. Annual performance appraisals were overdue in five of six staff files reviewed and senior staff confirmed these are now out of date for most staff.||An accurate recording system of staff education uptake is required to ensure the patients receive safe and effective services. All staff are required to have undertaken a performance appraisal within the preceding 12 months.||PA Moderate||Reporting Complete||05/08/2019|
|The organisation, through its infection control committee/infection control expert, determines the type of surveillance required and the frequency with which it is undertaken. This shall be appropriate to the size and complexity of the organisation.||The staff interviewed were aware of what types of infections are to be reported for surveillance purposes. It was not able to be established as to who was responsible for this role and/or the frequency of with which this surveillance was to be undertaken.||The type and frequency of surveillance required is determined for the size and complexity of the organisation and a staff member has responsibility for the documented surveillance programme.||PA Low||Reporting Complete||05/08/2019|
|Professional qualifications are validated, including evidence of registration and scope of practice for service providers.||There is no process/system in place for the organisation to verify that all associated health professionals have a current practising certificate.||A system/process that enables the organisation to confirm professional registrations and scopes of practice are current is required.||PA Low||Reporting Complete||20/09/2019|
|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 no overall organisational risk management plan/register to enable ongoing and potential risks to be monitored, analysed and evaluated for quality improvement purposes.||A risk register is implemented to enable the identification, monitoring, analysis, evaluation and review of potential and ongoing organisational risks that are reviewed at a frequency determined by the severity of the risk and the probability of change in the status of the risk.||PA Moderate||Reporting Complete||04/11/2019|
|Key components of service delivery shall be explicitly linked to the quality management system.||Not all aspects of service delivery are being integrated into the quality and risk management system. For example: • There was no evidence to show that restraint minimisation and safe practice is reported at the clinical governance, or clinical advisory levels of the quality system • Infection control reporting is no longer occurring • Patient satisfaction surveys have not been completed • Internal audit results of aspects of service delivery were not available • Health and safety internal audit… (this text has been trimmed due to space limits).||All aspects of service delivery, including restraint minimisation, infection control, associated internal audit outcomes, patient surveys, health and safety and aspects of service delivery requiring quality improvement are integrated into the organisational quality and risk management system.||PA Moderate||Reporting Complete||04/11/2019|
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: 01 April 2019
Audit type:Surveillance Audit
- Te Whare Hauora o Ngati Porou - Apr 2019 (docx, 40.61 KB)
- Te Whare Hauora o Ngati Porou - Apr 2019 (pdf, 161.46 KB)
Audit type:Certification Audit
- Te Whare Hauora o Ngati Porou - Aug 2017 (docx, 55.57 KB)
- Te Whare Hauora o Ngati Porou - Aug 2017 (pdf, 194.33 KB)
Audit type:Surveillance Audit
- Te Whare Hauora o Ngati Porou - Jul 2016 (docx, 33.18 KB)
- Te Whare Hauora o Ngati Porou - Jul 2016 (pdf, 132.52 KB)
Audit type:Certification Audit