Ultimate Care Palliser House

Profile & contact details

Premises details
Premises nameUltimate Care Palliser House
Address 186 East Street Greytown 5712
Total beds32
Service typesMedical, Dementia care, Rest home care
Certification/licence details
Certification/licence nameThe Ultimate Care Group Limited - Ultimate Care Palliser House
Current auditorCentral Region's Technical Advisory Services Limited
End date of current certificate/licence01 September 2023
Certification period24 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: 15 June 2021

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
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 ModerateIn Progress
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 ModerateIn Progress
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 ModerateIn Progress
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 LowIn Progress
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 ModerateIn 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.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 LowIn Progress
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 ModerateIn Progress
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 ModerateIn Progress
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 LowIn Progress
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 LowIn Progress
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 ModerateIn 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.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 ModerateIn Progress
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 ModerateIn Progress
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 ModerateIn Progress
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 LowReporting Complete17/09/2021

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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