Thornbury House

Profile & contact details

Premises details
Premises nameThornbury House
Address 30 Eskvale Street Saint Kilda Dunedin 9012
Total beds33
Service typesDementia care
Certification/licence details
Certification/licence nameElsdon Enterprises Limited - Thornbury House
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence06 November 2024
Certification period36 months
Provider details
Provider nameElsdon Enterprises Limited
Street address 1 Taaffes Glen Road Rangiora 7472
Post address1 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: 16 September 2021

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
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.There was no documentation to evidence progression towards meeting goals for all aspects of the care plan in five residents who had been in the facility for more than six months. Ensure the care plan review documents evidence towards the resident’s achievement towards meeting goals for all aspects of the care plan at least six-monthly. PA LowIn Progress
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).i) There was no documented evidence to indicate that external contractors undergo health and safety orientation. ii) A hoist is available, but staff have not undergone specific training on the use of the hoist. Examples were provided by caregiver staff that indicates they and the residents are at risk of an injury when assisting in lifting a resident who has fallen. i) Ensure there is documented evidence of external contractors being orientated to the health and safety procedures of Thornbury House. ii) Ensure staff undergo training on the use of the hoist that was recently purchased. PA LowIn Progress
The use of enablers shall be voluntary and the least restrictive option to meet the needs of the consumer with the intention of promoting or maintaining consumer independence and safety.The caregivers and clinical nurse leader interviewed indicated that there is one resident, who is at a high risk of falling, and has the legs elevated on their lazy-boy chair when they become agitated and are at risk of trying to stand and potentially fall. This use of restraint has been verbally discussed and approved by the son. But there is no evidence of a restraint assessment being completed. Nor is there evidence of regular monitoring of the resident when restraint is being used. … (this text has been trimmed due to space limits).Ensure restraint use is assessed, monitored, linked to the resident’s care plan and evaluated on a regular basis as per restraint policy and procedure. PA LowIn Progress
All buildings, plant, and equipment comply with legislation.Hot water temperature checks are routinely completed. When the temperatures at resident taps exceed 45 degrees, a corrective action is not implemented. Two examples were sighted whereby the recording of the temperature was 47 degrees Celsius. Ensure hot water temperatures for resident’s taps and showers do not exceed 45 degrees Celsius. PA LowIn Progress
Entry criteria, assessment, and entry screening processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies.There was no information provided to relatives around what to expect in a dementia unit including management of restraint and challenging behaviour as per the ARC contract Ensure relative receive information around what to expect in a dementia unit. PA LowIn Progress
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.(i). The care plan interventions did not provide sufficient instructions for care staff around resident cares including current mobility status, care of a dressing for a resident with a wound, doll therapy currently utilised for two residents, and one long-term care plan could not be located for a resident who had been in the service for more than three weeks. (ii). There were no individualised triggers, or specific strategies documented around de-escalation/ diversion strategies for six of si… (this text has been trimmed due to space limits).(i). Ensure interventions support all current assessed needs. (ii). Ensure the care plans include identification (where possible) of triggers, and document individualised strategies of de-escalation/ diversion for residents. (ii). Ensure care plans identify individual values, beliefs and privacy preferences. PA ModerateIn 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: 16 September 2021

Audit type:Certification Audit

Audit date: 12 March 2020

Audit type:Surveillance Audit

Audit date: 05 September 2018

Audit type:Certification Audit

Audit date: 01 November 2017

Audit type:Surveillance Audit

Audit date: 13 September 2016

Audit type:Certification Audit

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