Ultimate Care Karadean

Profile & contact details

Premises details
Premises name	Ultimate Care Karadean
Address	5 Queen Street Oxford 7430
Total beds	53
Service types	Physical, Intellectual, Rest home care, Geriatric, Medical

Certification/licence details
Certification/licence name	The Ultimate Care Group Limited - Ultimate Care Karadean
Current auditor	Central Region's Technical Advisory Services Limited
End date of current certificate/licence	03 December 2023
Certification period	36 months

Provider details
Provider name	The Ultimate Care Group Limited
Street address	Level 2 111 Johnsonville Road Johnsonville Wellington 6037
Post address	PO Box 425 Waterloo Quay Wellington 6140
Website	www.ultimatecare.co.nz/

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: 03 May 2022

Outcome required	Found at audit	Action required	Risk rating	Action status	Date action reported complete
Infection control education is provided by a suitably qualified person who maintains their knowledge of current practice.	The IPCC has not completed infection prevention and control education for the infection prevention and control role.	Ensure the infection prevention and control education to staff is provided by a suitable qualified person with knowledge of current practice.	PA Low	Reporting Complete	12/03/2021
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.	i) Not all interRAI reassessments were completed and long-term care plans were not consistently evaluated within required six month timeframes. ii) The activities care plans were not always evaluated at the same time as the nursing care plans.	i) Ensure the interRAI reassessments and the long-term nursing care plan are completed six-monthly. ii) Ensure that the activity care plan is evaluated and reviewed each time the long-term care plan is reviewed.	PA Moderate	Reporting Complete	12/03/2021
The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.	i) Hot water temperatures at the sanitary fixtures accessed by residents are not consistently monitored and exceed safe levels. ii) There is no evidence of a documented preventative maintenance plan for the facility buildings, equipment, and external grounds. iii) There is no evidence of the medication room temperature being monitored.	i) Ensure hot water temperatures are monitored and maintained within safe levels. ii) Develop and implement a preventative maintenance plan that minimises the risk of environmental harm to residents. ii) Ensure medication room temperatures are monitored and maintained within acceptable levels.	PA Moderate	Reporting Complete	12/03/2021
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.	i) Not all interRAI assessments and care plans are completed within 21 days of admission. ii) Staff response to call bells was not always actioned promptly.	i) Ensure all interRAI assessments and care plans are completed within 21 days of the residents’ admission. ii) Ensure call bells are answered promptly by staff.	PA Moderate	Reporting Complete	12/03/2021
The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk.	Unwitnessed falls records do not consistently evidence neurological observations.	Ensure neurological observations are conducted and documented post unwitnessed falls.	PA Low	Reporting Complete	12/03/2021
There is a document control system to manage the policies and procedures. This system shall ensure documents are approved, up to date, available to service providers and managed to preclude the use of obsolete documents.	Hard copy policies and procedures available in the facility do not consistently evidence the latest version of the document.	Ensure all hard copies of policies and procedures available to staff reflect current documentation.	PA Low	Reporting Complete	12/03/2021
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.	Quality improvement data is not consistently reported, evaluated, and communicated to service providers.	Ensure quality improvement data is consistently reported, evaluated, and communicated to service providers.	PA Moderate	Reporting Complete	12/03/2021
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.	A corrective action plan addressing the areas identified as requiring improvement is not consistently implemented from meetings, residents’ surveys, residents’ incidents reports and internal audits.	Implement a corrective action plan addressing all areas identified as requiring improvement.	PA Moderate	Reporting Complete	12/03/2021
Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services.	Whenever an RN is not available an enrolled nurse or level 4 qualified caregiver who have a current first aid certificate and medication competency cover for these shifts, with the backup of the telephone, clinical UCG nurse call system.	The service is to ensure there is 24/7 RN cover.	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: 03 May 2022

Audit type:Surveillance Audit

Audit date: 13 October 2020

Audit type:Certification Audit

Audit date: 11 June 2019

Audit type:Surveillance Audit

Audit date: 03 October 2017

Audit type:Certification Audit

Audit date: 12 April 2016

Audit type:Surveillance Audit

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