Thornbury House
Profile & contact details
| Premises name | Thornbury House |
|---|---|
| Address | 30 Eskvale Street Saint Kilda Dunedin 9012 |
| Total beds | 33 |
| Service types | Dementia care |
| Certification/licence name | Phantom 2021 Limited - Thornbury House |
|---|---|
| Current auditor | Health and Disability Auditing New Zealand Limited |
| End date of current certificate/licence | 19 December 2026 |
| Certification period | 36 months |
| Provider name | Phantom 2021 Limited |
|---|---|
| Street address | 35 Centennial Avenue Milton 9220 |
| Post address | 35 Centennial Avenue Milton 9220 |
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: 28 September 2023
| Outcome required | Found at audit | Action required | Risk rating | Action status | Date action reported complete |
|---|---|---|---|---|---|
| Results of surveillance and recommendations to improve performance where necessary shall be identified, documented, and reported back to the governance body and shared with relevant people in a timely manner. | There was no documented evidence of daily outbreak meetings, or a completion of an outbreak review (lessons learned) as required by policy. | Ensure debrief meetings and outbreak reviews occur. | PA Low | In Progress | |
| Fundamental to the development of a care or support plan shall be that: (a) Informed choice is an underpinning principle; (b) A suitably qualified, skilled, and experienced health care or support worker undertakes the development of the care or support plan; (c) Comprehensive assessment includes consideration of people’s lived experience; (d) Cultural needs, values, and beliefs are considered; (e) Cultural assessments are completed by culturally competent workers and are accessible in all settin… (this text has been trimmed due to space limits). | Four of six residents’ files reviewed did not have updated interventions for bowel management, recent weight loss, decreased mobility and changes to behaviour. | Ensure care plan interventions are updated as the residents’ needs change | PA Low | In Progress | |
| Service providers shall follow the National Adverse Event Reporting Policy for internal and external reporting (where required) to reduce preventable harm by supporting systems learnings. | (i)Where altercations/ incidents involve two residents only the primary resident and not the secondary resident is identified; therefore, (a) no incident report form in the secondary resident`s file evident;(b) No evidence that the secondary resident`s family/whānau were notified. (ii)Where family were not notified it was not evident on the incident form or progress notes the reason for not notifying. (iii) Where family were notified, it was not evident in five incident report forms when they … (this text has been trimmed due to space limits). | (i-iii) Ensure the incident process and family/whānau notification process is managed as per policy. | PA Moderate | In Progress |
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.
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 reports
Audit date: 28 September 2023Audit type:Certification Audit
Audit date: 15 November 2022Audit type:Provisional Audit