Ultimate Care Churtonleigh

Profile & contact details

Premises details
Premises nameUltimate Care Churtonleigh
Address 24 Mallard Grove Churton Park Wellington 6037
Total beds36
Service typesRest home care, Geriatric, Medical
Certification/licence details
Certification/licence nameThe Ultimate Care Group Limited - Ultimate Care Churtonleigh
Current auditorCentral Region's Technical Advisory Services Limited
End date of current certificate/licence30 April 2025
Certification period36 months
Provider details
Provider nameThe Ultimate Care Group Limited
Street addressLevel 2 111 Johnsonville Road Johnsonville Wellington 6037
Post addressPO Box 425 Waterloo Quay Wellington 6140

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: 19 September 2023

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
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 is consistently above the required maximum level of 25⁰C.Ensure that the temperature of the medication room is kept below 25⁰C.PA ModerateReporting Complete22/07/2022
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.(i) Outcomes for corrective actions are not documented, inclusive of evaluations prior to sign off. (ii) Quality, health and safety, staff meetings do not fully inform staff of evaluations and outcomes.(i) Outcomes and evaluations of corrective actions should be documented. (ii) Quality, health and safety, staff meetings should clearly outline corrective actions and improvementsPA LowReporting Complete08/08/2022
The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.(i) Records demonstrated that the temperatures had been above 45 degrees celsius for all of 2021, mitigation regarding this was auctioned during the audit and is ongoing. (ii) There is an area in the outside garden which has an unstable sump cover and a path which is inundated by tree roots, both of which are unsafe for residents and visitors.(i) Ensure that temperatures in resident areas meet the required 45 degrees celsius. (ii) Ensure that the outside environment is safe for resident and visitor mobility. PA ModerateReporting Complete16/08/2022
There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.(i)The facility does not have 24/7 RN cover as required under the aged related residential care agreement, mitigation of this risk with monitoring by the district health board has been out into place (ii) Caregiving staff mix and levels meet the aged related residential care agreement, however the layout of the facility and the domestic duties carried out by afternoon and night staff are not taken into consideration within the roster tool. (i) Ensure there is 24/7 RN cover (ii) Ensure that staffing levels are set to meet both clinical and domestic requirements taking into consideration both facility layout and the needs (acuity) of residents.PA ModerateReporting Complete03/10/2023
Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services.The provider is unable to provide 24/7 RN cover as per contractual obligations. Ensure there is 24/7 RN cover as contractual obligations PA ModerateIn Progress
Surveillance methods, tools, documentation, analysis, and assignment of responsibilities shall be described and documented using standardised surveillance definitions. Surveillance includes ethnicity data.Surveillance reports do not include the resident’s ethnicity. Ensure surveillance reports include the resident’s ethnicity. PA LowIn 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.

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