Ultimate Care Cambridge Oakdale

Profile & contact details

Premises details
Premises nameUltimate Care Cambridge Oakdale
Address 58 Tennyson Street Leamington Cambridge 3432
Total beds47
Service typesRest home care, Geriatric, Medical, Dementia care
Certification/licence details
Certification/licence nameThe Ultimate Care Group Limited - Ultimate Care Cambridge Oakdale
Current auditorThe DAA Group Limited
End date of current certificate/licence02 November 2019
Certification period36 months
Provider details
Provider nameThe Ultimate Care Group Limited
Street addressLevel 2 111 Johnsonville Road Johnsonville Wellington 6037
Post addressPO Box 13120 Johnsonville Wellington 6440

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: 30 August 2016

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
New service providers receive an orientation/induction programme that covers the essential components of the service provided.Four of the eight staff files reviewed had no evidence of a completed orientation. All staff are to have evidence of a completed orientation held on their file. PA LowIn Progress
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.(i) On-going education via study days has not been consistent and as a result there are staff who have not received all ongoing education as required. Because the individual records of staff education are not up to date and the 2015 education folder is no longer available, it was difficult to ascertain what staff had attended education and when. (ii)Three care staff working in the dementia unit have not commenced the specific dementia education. It is acknowledged that they will be starting in S… (this text has been trimmed due to space limits).(i) On-going education is to be provided to all staff on a regular basis. (ii) All care staff who work in the dementia unit are to have completed the dementia unit standards no later than 12 months after their appointment. (iii) All clinical staff are to have a current competency assessment for restraint minimisation and safe practice. PA LowIn Progress
Information of a private or personal nature is maintained in a secure manner that is not publicly accessible or observable.The outside storage shed was observed to be unlocked. The archived boxes with residents’ archived files were directly placed on top of each other and damp, as they have direct contact with floor of the storage shed. Ensure that all consumer information is stored in a secure location, is easily accessible when required, and protected from the risk of damage to documents. PA LowIn Progress
Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer.In six of the seven files reviewed, no infection identification forms or supporting short term care plans were completed. Four of the seven files reviewed did not evidence multidisciplinary meetings. Four of seven files evidenced residents with weight loss, however no short term care plans or discussions with GP was evident. Provide evidence that each stage of service provision is undertaken to meet DHB contractual requirements and policy requirements. PA LowIn Progress
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.Apart from the health and safety meeting minutes, there was no documented evidence that quality improvement data is being reported back to staff. Provide documented evidence that quality improvement data is reported back to all staff on a regular basis. PA LowIn Progress
Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.Residents and staff discussions/feedback have stated there are residents with reduced/limited mobility who are unable to access the facility van, and thus access to events in the community. Review the availability of access for all residents when using the facility van to support involvement in community activities. PA LowIn 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.Eight of 27 medication charts did not have the reason for use of prescribed PRN medications. A registered nurse was observed giving two rest home residents medication from another resident’s prescribed medication bottle. All staff who are responsible for medicine management are required to meet the requirements of legislation, protocols and guidelines. PA ModerateReporting Complete31/03/2017

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. 

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.

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