Ultimate Care Rhapsody
Profile & contact details
|Premises name||Ultimate Care Rhapsody|
|Address||30 Mill Road Lower Vogeltown New Plymouth 4310|
|Service types||Geriatric, Medical, Rest home care|
|Certification/licence name||Melody Enterprises Limited - Ultimate Care Rhapsody|
|Current auditor||Central Region's Technical Advisory Services Limited|
|End date of current certificate/licence||23 May 2022|
|Certification period||36 months|
|Provider name||Melody Enterprises Limited|
|Street address||111 Johnsonville Road Johnsonville Wellington 6037|
|Post address||PO Box 13120 Johnsonville Wellington 6440|
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: 12 January 2021
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|The facilitation of safe self-administration of medicines by consumers where appropriate.||Safe storage is not provided for residents self-administering medication.||Ensure that safe storage for residents self-administering medication is provided.||PA Moderate||Reporting Complete||17/03/2021|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||The local system used at Ultimate Care Rhapsody to record mandatory education of individual staff is inconsistent and unable to readily provide evidence of relevant mandatory training. This has resulted in three identified gaps which need to be addressed. The system currently used cannot provide assurance all staff have attended the mandatory sessions as required.||Provide evidence the infection control RN, second checkers of medication and the cook have the education required for their roles and that the system used ensures these and other mandatory education competencies are tracked and action taken as required to maintain currency of all staff education.||PA Moderate||Reporting Complete||21/06/2019|
|The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code.||Two complaints acknowledged as being high risk were not escalated as required by Ultimate Care Group policy.||Ensure all complaints are risk rated and escalated to relevant senior managers as required by the organisation’s policy.||PA Low||Reporting Complete||16/10/2019|
|Information is entered into the consumer information management system in an accurate and timely manner, appropriate to the service type and setting.||The consumer information management system currently in place does not enable information to be entered and retrieved in an accurate and timely manner.||Provide evidence consumer information is entered into a consumer information system in an accurate and timely manner.||PA Low||Reporting Complete||16/10/2019|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Service delivery plans do not always describe the required support the resident requires to meet their desired outcomes.||Provide evidence care plans describe fully the care the residents’ require.||PA Moderate||Reporting Complete||16/10/2019|
|Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.||The Ultimate Care Rhapsody Emergency Plan does not include all relevant required information to guide staff to respond appropriately in an emergency.||Ensure there is adequate water stored and available to residents and staff at Ultimate Care Rhapsody in an emergency. Update the emergency plan with accurate, information which includes the location of the emergency water supply, the local Civil Defence Centre and all other information required by the Ultimate Care Group templates.||PA Low||Reporting Complete||16/10/2019|
|Alternative energy and utility sources are available in the event of the main supplies failing.||There is no assurance that the required emergency water supplies are available to residents and staff of Ultimate Care Rhapsody in an emergency.||Provide an adequate emergency water supply as required by Ultimate Care Group policy.||PA Low||Reporting Complete||16/10/2019|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Meeting minutes did not consistently evidence that actions arising, responsibilities, timeframes and sign off had been documented and implemented.||Ensure that corrective action plans arising are fully documented and implemented for all meetings conducted at the facility.||PA Low||In Progress|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Human resource processes relating to orientation and performance reviews are not always conducted in accordance with good employment practice and meet the requirements of legislation.||Ensure human resource processes relating to orientation and performance reviews are conducted in accordance with good employment practice and meet the requirements of legislation.||PA Moderate||In Progress|
|Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include: (a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk; (b) A process that addresses/treats the risks associated with service provision is developed and im… (this text has been trimmed due to space limits).||The facility’s hazard register is not current.||Ensure the hazard register is current.||PA Low||In 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.||Residents’ unwitnessed falls did not have evidence of appropriate neurological observations being completed.||Ensure that full neurological observations are completed for all residents who experience unwitnessed falls.||PA Moderate||In Progress|
|Consumers have a right to full and frank information and open disclosure from service providers.||Not all required information is provided to new residents and their family on admission to the facility.||Ensure all new residents and their family are provided with detailed information about the services provided at the facility.||PA Low||In Progress|
|All buildings, plant, and equipment comply with legislation.||i) Building warrant of fitness expired on 14/01/2021. ii) There are two residents residing in a single room.||i) Ensure the BWOF is current. ii) Ensure single rooms are used for single occupancy.||PA Moderate||Reporting Complete||15/02/2021|
|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) Corrective actions had not been developed or implemented to address drug room temperatures of above 25 degrees celsius. ii) Information relating to residents allergies and sensitivities was inconsistently documented.||i) Ensure corrective action is taken to ensure drug room temperatures are always within recommended range. ii) Ensure all information relating to residents’ allergies and sensitives is clearly documented.||PA Moderate||Reporting Complete||17/03/2021|
|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) Long-term care plans are not consistently evaluated within the required timeframes or when changes occur. ii) Long-term care plans are not consistently available to staff caring for residents. iii) Long-term care plans have not been developed for all residents within the required timeframes.||i) Ensure that long -term care plan evaluations are completed with the required timeframes or when changes occur. ii) Ensure that resident information including long-term care plans are accessible for all RNs and HCAs. iii) Ensure all residents have a long-term care plan developed within the required timeframes||PA Moderate||Reporting Complete||25/03/2021|
|Where progress is different from expected, the service responds by initiating changes to the service delivery plan.||Evaluation of the long-term care plans is not being carried out in accordance with HDSS and the DHB contract.||Ensure evaluation of long-term care plans is carried as per HDSS and DHB contract.||PA Moderate||Reporting Complete||25/03/2021|
|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 requirements of the Code.||Ensure that all complaints are managed in line with the requirements of the Code.||PA Moderate||Reporting Complete||19/07/2021|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||The complaints register was not up to date.||Ensure that an up to date complaints register is maintained of all complaints.||PA Low||Reporting Complete||19/07/2021|
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: 12 January 2021
Audit type:Surveillance Audit
- Ultimate Care Rhapsody - Jan 2021 (docx, 39.87 KB)
- Ultimate Care Rhapsody - Jan 2021 (pdf, 156.25 KB)
Audit type:Certification Audit
- Ultimate Care Rhapsody - Mar 2019 (docx, 49.88 KB)
- Ultimate Care Rhapsody - Mar 2019 (pdf, 190.91 KB)
Audit type:Surveillance Audit
- Ultimate Care Rhapsody - Aug 2017 (docx, 35.13 KB)
- Ultimate Care Rhapsody - Aug 2017 (pdf, 136.03 KB)
Audit type:Certification Audit
- Ultimate Care Rhapsody - Mar 2016 (docx, 48.52 KB)
- Ultimate Care Rhapsody - Mar 2016 (pdf, 187.49 KB)
Audit type:Surveillance Audit
- Ultimate Care Rhapsody - Oct 2015 (docx, 34.27 KB)
- Ultimate Care Rhapsody - Oct 2015 (pdf, 133.4 KB)
Audit type:Surveillance Audit