Ultimate Care Poneke House
Profile & contact details
|Premises name||Ultimate Care Poneke House|
|Address||135 Constable Street Newtown Wellington 6021|
|Service types||Dementia care, Rest home care, Geriatric, Medical|
|Certification/licence name||The Ultimate Care Group Limited - Ultimate Care Poneke House|
|Current auditor||Central Region's Technical Advisory Services Limited|
|End date of current certificate/licence||06 August 2022|
|Certification period||48 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: 07 July 2020
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date 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.||i) Weekly medication checks are not always conducted. ii) Some medicines are transcribed by RNs.||i) Provide evidence of weekly medication checks. ii) Ensure medications are not transcribed.||PA Moderate||Reporting Complete||09/11/2020|
|The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code.||Not all complaints were managed in line with the Code, including: i) Eight of thirteen documented complaints did not meet the timelines required by the Code. ii) Five of thirteen complaints had not had not be documented on a complaint form. ii) Two of the eight documented complaint forms had not been signed off.||Ensure that all complaints are managed in-line with the requirements of the Code.||PA Low||Reporting Complete||09/11/2020|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||i) Seven of thirteen documented complaints reviewed had not been added to the complaints register. ii) Three of five complaints logged on the complaints register did not have supporting documentation available int the complaint file.||Ensure that: i) An up to date complaints register is maintained of all complaints. ii) Supporting documentation for each complaint is maintained on the complaints register.||PA Low||Reporting Complete||09/11/2020|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Staff meeting minutes did not consistently evidence that actions arising, responsibilities, timeframes and sign off had been documented.||Ensure that corrective action points arising are fully documented for all staff meeting minutes.||PA Low||Reporting Complete||09/11/2020|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||Five of six staff files reviewed did not have evidence of a current performance appraisal.||Ensure all staff undergo an annual performance appraisal.||PA Low||Reporting Complete||09/11/2020|
|Consumers who have additional or modified nutritional requirements or special diets have these needs met.||Residents’ food preferences, special diets and serving sizes are recorded, however not always followed.||Ensure kitchen staff follow the residents’ individualised dietary assessments.||PA Low||Reporting Complete||09/11/2020|
|The facilitation of safe self-administration of medicines by consumers where appropriate.||Self-administration of medication competency assessments and three-monthly reviews are not always conducted. Monitoring of the administration of medicines and safe storage were not provided.||Ensure self-administration of medicines is conducted according to policy and guidelines.||PA Moderate||Reporting Complete||09/11/2020|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||i) Food temperatures, fridge and freezer temperatures and kitchen cleaning records are not consistently recorded or accessible by all staff. ii) Emergency water supply is insufficient, not current and stored in residents’ rooms, bathrooms and the kitchen.||i) Ensure all food related temperature monitoring and cleaning of kitchen is recorded consistently. ii) Ensure emergency water supply is sufficient for this facility, current and stored appropriately.||PA Low||Reporting Complete||09/11/2020|
|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) Residents’ admission agreements do not always evidence sign off, as per aged residential care timeframes. ii) General practitioner exceptions are not consistently noted and signed by the GP for residents to be medically examined less frequently than monthly. iii) The interRAI assessments are not consistently completed within the 21 days of resident’s admission to the facility. iv) The long-term care plans are not consistently completed within 21 days of the residents’ admission to the facilit… (this text has been trimmed due to space limits).||i) Ensure residents’ admission agreements are signed within the required timeframe. ii) Ensure the GP exceptions are noted and signed by the GP for residents to be medically examined less frequently than monthly. iii) Ensure the interRAI assessments are completed within the 21 days of resident’s admission to the facility. iv) Ensure the long -term care plans are completed within 21 days of the residents’ admission to the facility. v) Ensure the residents’ progress notes record times of entry. v… (this text has been trimmed due to space limits).||PA Moderate||Reporting Complete||09/11/2020|
|The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.||i) Cracked and lifting floor coverings and peeling paint were observed in resident communal bathrooms and toilets. ii) Communal toilets required cleaning. iii) Shower floors were observed to be left wet and slippery after patient showering. iv) A blood pressure monitor evidenced a last calibration check of 2018. v) Large four litre containers of shampoo and bodywash were available for communal use in showers room. vi) Unprotected oil fin heaters were used for heating in some resident rooms in th… (this text has been trimmed due to space limits).||Ensure that: i) All surfaces maintained to a satisfactory standard. ii) Resident toilets are regularly cleaned when required after use. iii) Shower floors mopped after patient showering. iv) All equipment has evidence of a current calibration check. v) Residents have a personal supply of toiletries and that communal toiletries are not available for use. vi) Heating in areas accessed by residents is safe. vii) All fire exit doors can be exited safely and quickly in the advent of an emergency. … (this text has been trimmed due to space limits).||PA Moderate||Reporting Complete||09/11/2020|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||Service provision in the dementia unit relating to challenging behaviour management does not always record strategies to manage challenging behaviours.||Ensure individualised interventions for residents with dementia who have challenging behaviours are recorded to guide staff in their management.||PA Moderate||Reporting Complete||09/11/2020|
|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.||Not all incidents/accidents were documented on incident forms and not all residents who had an un-witnessed fall received neurological observations in accordance with best practice.||Ensure that: All resident incidents/accidents are documented and reported on an incident form and all unwitnessed falls receive neurological observations in accordance with best practice.||PA Low||Reporting Complete||09/11/2020|
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.
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.
Audit reportsAudit date: 07 July 2020
Audit type:Surveillance Audit
- Ultimate Care Poneke House - Jul 2020 (docx, 39.68 KB)
- Ultimate Care Poneke House - Jul 2020 (pdf, 158.48 KB)
Audit type:Certification Audit
- Ultimate Care Poneke House - May 2018 (docx, 47.74 KB)
- Ultimate Care Poneke House - May 2018 (pdf, 182.84 KB)
Audit type:Partial Provisional Audit
- Ultimate Care Poneke House - Nov 2017 (docx, 32.37 KB)
- Ultimate Care Poneke House - Nov 2017 (pdf, 110.77 KB)
Audit type:Surveillance Audit