Profile & contact details
|Premises name||Thornbury House|
|Address||30 Eskvale Street Saint Kilda Dunedin 9012|
|Service types||Dementia care|
|Certification/licence name||Elsdon Enterprises Limited - Thornbury House|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||06 November 2021|
|Certification period||36 months|
|Provider name||Elsdon Enterprises Limited|
|Street address||1 Taaffes Glen Road Rangiora 7472|
|Post address||1 Taafes Glen Road RD 2 Rangiora 7472|
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: 12 March 2020
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Long-term care plans for five residents did not include all goals and interventions to support all assessed needs. Interventions reviewed lacked sufficient detail to guide staff around continence management, challenging behaviours, communication, mobility, spiritual preferences, skin care and in the 24-hour DT plan,||Ensure that each resident had a detailed care plan in place which describes all cares and interventions required to guide staff in the provision of care.||PA Moderate||Reporting Complete||14/01/2019|
|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.||Four of four long-term care plan evaluations did not record progress towards achieving documented goals.||Ensure progress towards achieving goals is documented||PA Low||Reporting Complete||14/01/2019|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Three of six staff files do not have current appraisals completed.||Ensure all staff have a current annual appraisal.||PA Low||In Progress|
|Service providers responsible for medicine management are competent to perform the function for each stage they manage.||The two RNs did not have current medication competencies in place.||Ensure all staff administering medications have a current medicine competency which is reviewed at least annually.||PA Low||In Progress|
|The appointment of appropriate service providers to safely meet the needs of consumers.||The cooks file reviewed was incomplete and had no evidence of qualifications, police check, or reference checks.||Ensure all employee files are fully completed at the time of employment.||PA Low||In Progress|
|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.||(i) No education or debrief was held around outbreak management post July 2019 outbreak (ii) No current infection control programme is in place. (iii) The IC coordinator has not had training in infection control.||(i) Ensure ongoing education is evidenced as provided to all staff. (ii) Ensure a current infection control programme is in place. (iii) Ensure the infection control coordinator attends training around current infection control practices and guidelines.||PA Low||In Progress|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||The complaint register held prior to September 2019 could not be located.||Ensure the complaint register is maintained documenting all complaints.||PA Low||In Progress|
|All buildings, plant, and equipment comply with legislation.||Preventative maintenance schedules could not be located since May 2019.||Ensure all preventative maintenance records are maintained.||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.||(i) Neurological observations have not been fully completed according to policy in seven of seven incidents of unwitnessed falls. (ii) Ten of ten incident reports did not document opportunities to minimise future risks.||(i) Ensure neurological observations are either completed as per policy or have been discontinued by an RN. (ii) Ensure opportunities where possible to minimise risks are identified||PA Low||In Progress|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Long term care plans were not updated or Short term care plans established for assessed changes in health status for example (i) one resident with an infection and on an antibiotics did not have any interventions to support this, (ii) a resident with unintentional weight loss did not have any interventions documented to support gaining weight, The same resident had a risk of choking and there were no interventions to minimise the risk of this and (iii) one resident who had transferred back from … (this text has been trimmed due to space limits).||Ensure long-term care plans are updated or short-term care plans established for assessed changes in health status||PA Moderate||In Progress|
|The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.||RN progress notes in five of five files reviewed had gaps of up to one month.||Ensure the RN documents regularly in resident progress notes.||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.||Food and fluid monitoring was not completed for one resident identified with unintentional weight loss||Ensure food and fluid intake is monitored where required.||PA Low||In Progress|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||(i) The minutes of meetings held prior to September 2019 could not be located. (ii) The minutes of the meetings which have been held do not reflect discussions held, and do not evidence discussion around quality data. (iii) Internal audits completed prior to September 2019 could not be located. iv) Meetings with relatives and residents have not been occurring as per schedule.||(i). Ensure meeting minutes are filed and available to evidence meetings and discussions. ii) Ensure minutes of all meetings held, evidence discussions held with staff around quality data. (iii). Ensure internal audits are completed and filed as per schedule. (iv) Ensure meetings with residents and relatives occur as scheduled.||PA Low||In Progress|
|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 temperature of the medication room has not been recorded.||Ensure the medication room temperature is recorded and maintained below 25 degrees Celsius.||PA Low||In Progress|
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: 12 March 2020
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Certification Audit