Thornton Park Retirement Lodge

Profile & contact details

Premises details
Premises name	Thornton Park Retirement Lodge
Address	137 State Highway 35 RD 1 Opotiki 3197
Total beds	43
Service types	Rest home care, Geriatric, Medical

Certification/licence details
Certification/licence name	Thornton Park Retirement Village Limited - Thornton Park Retirement Lodge
Current auditor	Health and Disability Auditing New Zealand Limited
End date of current certificate/licence	11 January 2025
Certification period	36 months

Provider details
Provider name	Thornton Park Retirement Village Limited
Street address	137 State Highway 35 RD 1 Opotiki 3197
Post address	PO Box 550 Opotiki 3162

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: 24 July 2023

Outcome required	Found at audit	Action required	Risk rating	Action status	Date action reported complete
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.	The following shortfalls were identified: i) There was no evidence of a relative/resident feedback survey completed for 2019 and 2020. ii) The data for the resident/relative survey for 2021 had not been collated or discussed with staff and residents/relatives; and the recent food survey comments had not been documented as shared or discussed at various meetings. iii) Internal audit data including corrective actions, conformities and non-conformities had not been discussed at meetings since the… (this text has been trimmed due to space limits).	i)-ii) Ensure residents/relatives are surveyed to gather feedback on key components of the survey and the outcomes are communicated to residents, staff, and families as per policy. iii) Ensure all quality data including corrective actions, conformities and non-conformities are discussed and shared at meetings.	PA Moderate	Reporting Complete	06/06/2023
The appointment of appropriate service providers to safely meet the needs of consumers.	Seven staff files were reviewed, and one had a recent completed WIP. There was also no evidence of staff appraisals for 2019/2021 in the files reviewed.	Ensure staff appraisals are completed annually or quarterly Work in Progress as required by the policy.	PA Low	Reporting Complete	06/06/2023
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.	i-ii). There was no documented planned approach for 2019/2020 and not all compulsory topics including communication, including sensory and cognitive loss and other barriers to communication, and communication aids; cultural awareness and ageing process, including sensory, physical, psycho-social, spiritual, and cultural were held according to ARRC requirements. iii). The content of education sessions was not documented.	i-ii) Ensure a planned approach to training to ensure education/training schedules are adhered to and all staff completed at least eight hours of annual development as per ARRC requirements; and compulsory training components are covered. iii) Ensure content of education is documented.	PA Moderate	Reporting Complete	06/06/2023
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.	i) Three of seven resident positioning charts were not consistently completed. ii) Two hourly toileting detailed in the care plan was not recorded for one of seven residents. iii) One resident with chronic heart failure did not have daily weights completed and/or recorded consistently. iv) One resident did not have overnight checks documented as per their care plan.	i)-iv) Ensure all resident monitoring charts are fully completed in a timely manner and according to policy.	PA Moderate	Reporting Complete	06/06/2023
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.	Medication room temperatures are not monitored to ensure medication storage below 25°Celcius.	Ensure all medication is stored safely within the required temperature range.	PA Low	Reporting Complete	06/06/2023
All buildings, plant, and equipment comply with legislation.	There is no documented preventative maintenance schedule for the interior and exterior of the facility.	Ensure preventative maintenance is documented to ensure legislated standards are met.	PA Low	Reporting Complete	06/06/2023
Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care.	Not all policies and procedures were updated to meet the requirements of the new Standard.	Ensure all policies and procedures are updated to reflect the requirements of the new Standard.	PA Low	In Progress
Buildings, plant, and equipment shall be fit for purpose, and comply with legislation relevant to the health and disability service being provided. The environment is inclusive of peoples’ cultures and supports cultural practices.	There was no current building warranty of fitness in place.	Ensure there is a current building warranty of fitness in place.	PA Low	In Progress
Service providers shall engage with people receiving services to assess and develop their individual care or support plan in a timely manner. Whānau shall be involved when the person receiving services requests this.	(i). Four of the six files reviewed had no completed interRAI assessments for new residents. (ii). Two of the six files reviewed had interRAI assessments that were overdue for review. (iii). Five of six resident files reviewed had long-term care plans that were overdue for review.	(i)-(ii). Ensure interRAI assessments are completed as per contractual requirements. (iii). Ensure long-term care plans are reviewed at defined intervals as per policy and contractual requirements	PA Low	In Progress
Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services.	All night and afternoon shifts each week were not covered by a registered nurse, therefore not meeting the ARRC contract D17.4 a- i.	Ensure there is adequate coverage of all shifts by a registered nurse to meet the requirements of the ARRC contract D17.4 a-i.	PA Low	In Progress
Where required by legislation, there shall be a Fire and Emergency New Zealand- approved evacuation plan.	Approved fire evacuation plan and six-monthly fire drill records were not verified on audit days.	Ensure there is an approved fire evacuation plan in place and fire drills are completed six-monthly as per legislative requirements.	PA Low	In Progress
Service providers shall identify external and internal risks and opportunities, including potential inequities, and develop a plan to respond to them.	(i). Not all internal audits have been completed and results discussed during meetings since the previous audit. (ii). There was no evidence of a relative/resident feedback survey completed since the previous audit.	(i). Ensure internal audits are completed as per the audit schedule and results including corrective actions, conformities, and non-conformities are discussed during meetings. (ii). Ensure residents/relatives are surveyed to gather feedback on key components of the survey and the outcomes are communicated to residents, staff, and families as per policy.	PA Moderate	In Progress
Service providers shall implement systems to determine and develop the competencies of health care and support workers to meet the needs of people equitably.	Competencies for staff that include medication, first aid, fire, and hand washing were not completed as per policy requirements.	Ensure competencies are completed as per policy requirements.	PA Low	In Progress
The following aspects of the system shall be performed and communicated to people by registered health professionals operating within their role and scope of practice: prescribing, dispensing, reconciliation, and review.	(i). Ten of twelve medication charts sampled were overdue for review. (ii). Three of the twelve medication charts reviewed had no PRN indications for use documented. (iii). PRN outcomes were not consistently documented in 8 of 12 resident files reviewed.	(i). Ensure medication charts are reviewed as per policy and legislative requirements. (ii). Ensure PRN indications for use are consistently documented. (iii). Ensure PRN outcomes are documented as per policy requirements.	PA Moderate	In Progress
Service providers shall ensure there is a system to identify, plan, facilitate, and record ongoing learning and development for health care and support workers so that they can provide high-quality safe services.	Not all training was completed for staff as per the documented annual training plan in place.	Ensure training is completed as per the annual training plan.	PA Moderate	In Progress
Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided.	Two of the eight staff files reviewed had no completed orientation in place.	Ensure orientation is completed for all staff as per policy requirements.	PA Low	In Progress
Health care and support workers shall have the opportunity to discuss and review performance at defined intervals.	Two of the eight staff files reviewed had performance appraisals that were overdue for review.	Ensure staff performance appraisals are completed as per policy requirements.	PA Moderate	In Progress
Surveillance methods, tools, documentation, analysis, and assignment of responsibilities shall be described and documented using standardised surveillance definitions. Surveillance includes ethnicity data.	Surveillance of healthcare-associated infections was not including ethnicity data.	Ensure surveillance of infections includes ethnicity data.	PA Low	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: 24 July 2023

Audit type:Surveillance Audit

Audit date: 14 October 2021

Audit type:Certification Audit

Audit date: 15 October 2018

Audit type:Certification Audit

Audit date: 26 October 2017

Audit type:Surveillance Audit

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