Ultimate Care Palliser House
Profile & contact details
|Premises name||Ultimate Care Palliser House|
|Address||186 East Street Greytown 5712|
|Service types||Medical, Dementia care, Rest home care|
|Certification/licence name||The Ultimate Care Group Limited - Ultimate Care Palliser House|
|Current auditor||Central Region's Technical Advisory Services Limited|
|End date of current certificate/licence||01 September 2023|
|Certification period||24 months|
|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|
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: 15 June 2021
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Service providers have access to designated areas for the safe and hygienic storage of cleaning/laundry equipment and chemicals.||i) Laundry equipment and room size did not meet the needs of infection control and prevention or the workload for the facility. ii) The sluice and hose did not give staff protection from splash back, with either a splash guard or face shield provided. iii) The cleaner’s trolley had chemicals stored in an unsafe manner. iv) There was insufficient linen supply for the increase in resident numbers.||i) Ensure that the laundry equipment meets the requirements for a facility of 30 plus residents inclusive of infection control and prevention requirements. ii) Ensure that staff have adequate protection when handling soiled laundry. iii) Ensure that chemicals are stored securely on the cleaner’s trolley. iv) Ensure there is a sufficient supply of linen.||PA Moderate||Reporting Complete||15/10/2021|
|The organisation plans to ensure Māori receive services commensurate with their needs.||There are no links with community representative groups or support available for residents who identify as Māori.||Ensure that those residents who identify as Māori have support links to their community established.||PA Low||Reporting Complete||17/09/2021|
|Consumers have a right to full and frank information and open disclosure from service providers.||Family/enduring power of attorney are not always informed when an accident/incident affecting the resident occurs.||Ensure that family/enduring power of attorney is contacted when a resident suffers an accident/incident and that this is documented.||PA Moderate||Reporting Complete||15/10/2021|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||i) There is no evidence of trending of quality data or evaluation of outcomes. ii) Corrective actions discussed in staff and residents’ meetings are not followed up.||i) Ensure evaluation outcomes and trending of quality data is documented. ii) Ensure corrective actions discussed at meetings are followed through and progress towards achievements are documented, discussed and evidenced in meeting minutes.||PA Low||Reporting Complete||15/10/2021|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||Activities are not implemented as per approved activity programme.||Ensure that activities are implemented and documented as per activity programme.||PA Moderate||Reporting Complete||15/10/2021|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||i) There is no RN with designated responsibility for the oversight of the dementia unit. ii) The nurse manager’s roster tool does not reflect the increase in resident numbers and acuity. Consequently, there are gaps in staff levels and skill mixes with regard to HCAs actually required for resident care, and cleaning and laundry duties within shifts.||i) Ensure that there is an appropriately experienced RN designated with the responsibility for the dementia unit. ii) Ensure that as per policy the manager’s roster tool is implemented to ensure that staff mix and skill levels are maintained to meet requirements and resident needs.||PA Moderate||Reporting Complete||15/10/2021|
|Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.||The effectiveness of PRN medications is not documented consistently in the electronic system or in the progress notes.||Ensure the effectiveness of all PRN medications administered is documented.||PA Moderate||Reporting Complete||15/10/2021|
|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) Long-term care plans are not consistently developed within three weeks of admission. ii) There is no documentation of the exemption from monthly visits by the GP/nurse practitioner when the resident’s condition is considered stable.||i) Ensure that long-term care plans are developed within three weeks of admission. ii) Ensure that there is documented evidence of the resident’s condition being stable to allow for three-monthly reviews by the GP or nurse practitioner.||PA Low||Reporting Complete||15/10/2021|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||i) Long-term care plans do not contain sufficient information to address all residents assessed needs. ii) Short-term care plans do not contain sufficient information to guide resident care for acute problems.||i) Ensure that all long-term care plans contain sufficient detailed individualised interventions to manage residents’ assessed risks. ii) Ensure that short-term care plans describe interventions in sufficient detail to manage acute problems.||PA Low||Reporting Complete||15/10/2021|
|Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.||There are insufficient emergency supplies to sustain staff and residents in an emergency situation.||Ensure there are sufficient supplies to ensure sustainability in an emergency situation.||PA Moderate||Reporting Complete||15/10/2021|
|The appointment of appropriate service providers to safely meet the needs of consumers.||i) The facility has no RN who has had experience and training in the care of older people with dementia and the ageing process. ii) Not all shifts in the dementia unit have staff rostered on duty who have commenced or completed the NZQA, dementia unit standard training.||i) Ensure that the dementia unit has access to a RN who has had experience and training in the care of older people with dementia and the ageing process. ii) Ensure that staff employed to work in the dementia unit are enrolled in or have completed the NZQA dementia unit standards training.||PA Moderate||Reporting Complete||15/10/2021|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||Wound care is not carried out in accordance with policy or best practice.||Ensure that all wound care is carried out in accordance with policy and best practice.||PA Moderate||Reporting Complete||06/12/2021|
|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.||i) Resident allergies and sensitivities are not consistently documented on the electronic system. ii) Temperature monitoring of the medication room and medication fridge is carried out inconsistently.||i) Ensure all resident allergies and sensitivities are documented on the electronic medication system. ii) Ensure temperature monitoring of the medication fridge and medication room is carried out in accordance with policy.||PA Moderate||Reporting Complete||06/12/2021|
|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.||i) Neurological observations are not always completed, as per policy, following an un-witnessed fall or head injury. ii) Opportunities to reduce the future risks of a fall have not always been identified. iii) General practitioner instructions post accident/incident for monitoring/cares were not always documented as being followed up.||i) Ensure neurological observations are carried out post un-witnessed falls or head injury. ii) Ensure opportunities to reduce fall risk have been identified actioned and evaluated. iii) Ensure that GP instructions are followed up and documented.||PA Moderate||Reporting Complete||08/03/2022|
|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.||Progress notes, including RN reviews do not reflect residents’ current acuity and record information for ongoing care.||Ensure all information regarding residents’ health and progress is recorded in the progress notes.||PA Low||Reporting Complete||08/03/2022|
|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.||Interim care plans are not developed consistently within the required timeframe following admission.||Ensure that interim care plans are developed within the required timeframe following admission.||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.||(i) The DHB ARRC agreement requirements for 24/7 RN cover is not met, Rosters show that the covering staff member is not always over and above the normal staffing level. (ii) Staffing for resident acuity, facility layout and laundry/ domestic duties undertaken by caregivers does not consistently meet safe requirements. (iii) Annual staff appraisals have not been carried out as required.||(i) The service is to ensure there is 24/7 RN cover. (ii) Ensure that there is sufficient and safe staffing levels to meet residents’ needs. (iii) Ensure that staff appraisals are completed annually.||PA Moderate||In Progress|
|Meaningful activities shall be planned and facilitated to develop and enhance people’s strengths, skills, resources, and interests, and shall be responsive to their identity.||i) There is no oversight of the activity programme by a diversional therapist. ii) Activities are not implemented and documented as per activity programme displayed.||i) Ensure that a diversional therapist has oversight of the activity programme for residents living in the dementia unit. ii) Ensure that activities are implemented and documented as per activity programme displayed.||PA Moderate||In Progress|
|Service providers ensure competent health care and support workers manage medication including: receiving, storage, administration, monitoring, safe disposal, or returning to pharmacy.||i) The temperature of the medication room is not recorded. The temperature of the medication refrigerator is recorded inconsistently. ii) The weekly check of medications is inconsistent. The required six monthly stocktake of medications did occur but the CD register was not completed by the pharmacist.||i) Ensure that monitoring and recording of medication room and refrigerator temperatures is carried out in accordance with UCG policy. ii) Ensure that the check of medications occurs weekly. Ensure that required stocktake of medications occurs six monthly in accordance with UCG policy and legislation.||PA Moderate||In Progress|
|Service providers shall ensure there are safe and effective laundry services appropriate to the size and scope of the health and disability service that include: (a) Methods, frequency, and materials used for laundry processes; (b) Laundry processes being monitored for effectiveness; (c) A clear separation between handling and storage of clean and dirty laundry; (d) Access to designated areas for the safe and hygienic storage of laundry equipment and chemicals. This shall be reflected in a writt… (this text has been trimmed due to space limits).||Laundry equipment and products do not meet the needs of infection control and prevention.||Ensure that laundry equipment and products meet the requirements for infection prevention and control.||PA Moderate||In Progress|
The outcome required by the Health and Disability Services Standards.
Found at audit
The issue that was found when the rest home was audited.
The action necessary to fix the issue, as decided by the auditor.
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.
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.
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 reportsAudit date: 15 June 2021
Audit type:Certification Audit
- Ultimate Care Palliser House - Jun 2021 (docx, 51.23 KB)
- Ultimate Care Palliser House - Jun 2021 (pdf, 201.44 KB)
Audit type:Partial Provisional Audit
- Ultimate Care Palliser House - Jan 2021 (docx, 53.54 KB)
- Ultimate Care Palliser House - Jan 2021 (pdf, 136.25 KB)
Audit type:Surveillance Audit
- Ultimate Care Palliser House - Dec 2019 (docx, 41.43 KB)
- Ultimate Care Palliser House - Dec 2019 (pdf, 164.14 KB)
Audit type:Partial Provisional Audit