Ultimate Care Rose Lodge
Profile & contact details
|Premises name||Ultimate Care Rose Lodge|
|Address||129 Tweed Street West Invercargill Invercargill 9810|
|Service types||Rest home care, Geriatric, Medical|
|Certification/licence name||The Ultimate Care Group Limited - Ultimate Care Rose Lodge|
|Current auditor||Central Region's Technical Advisory Services Limited|
|End date of current certificate/licence||02 March 2024|
|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: 07 December 2021
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Consumers are informed of their rights to an independent advocate, how to access them, and their right to have a support person/s of their choice present.||There is no information regarding advocacy services given to residents or whānau on admission or displayed. Staff were unaware of this service.||Ensure that information on advocacy services are made available to residents and whānau and that staff training in advocacy services occurs.||PA Low||Reporting Complete||14/07/2022|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||(i) Outcomes for corrective actions are not documented, inclusive of evaluations prior to sign off. (ii) Quality, health and safety, staff meetings do not fully inform staff of evaluations and outcomes.||(i) Outcomes and evaluations of corrective actions should be documented. (ii) Quality, health and safety, staff meetings should clearly outline corrective actions and improvements||PA Low||Reporting Complete||14/07/2022|
|Professional qualifications are validated, including evidence of registration and scope of practice for service providers.||(i) Staff appraisals have not been carried out as per policy. (ii) Job descriptions and completed orientations were not in new staff files.||(i) Ensure that staff appraisals occur as per policy. (ii) Ensure that all new staff have job descriptions and orientation training sign off.||PA Low||Reporting Complete||14/07/2022|
|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 have not been recorded or fully actioned when the medication room temperatures have been above the normal range. (ii)The pharmacy stocktake had not occurred in the past six months as required.||(i) Ensure that a corrective action is put into place and documented when the temperature of the medication room is above the normal range. (ii) Ensure that the required stocktake of medication is completed every six months.||PA Moderate||Reporting Complete||14/07/2022|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||Registered nurses cover does not meet the requirements of hospital level care agreement.||Ensure that there is adequate RN cover for all shifts at the facility to meet the requirements of hospital level care.||PA High||Reporting Complete||14/07/2022|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||Staff responsible for preparing and serving food at Ultimate Care Rose Lodge do not have food hygiene certificates.||Ensure that all staff involved in preparation and serving food have food hygiene certificates.||PA Moderate||Reporting Complete||14/07/2022|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i) Residents did not consistently have a full suite of neurological observations completed following an unwitnessed fall in accordance with Ultimate Care Group policy and best practice. (ii) The exception from monthly GP visits is not documented.||(i) Ensure a full suite of neurological observations are conducted and documented following all unwitnessed falls. (ii) Ensure that the exception from monthly GP visits is documented in the residents’ clinical records.||PA Low||Reporting Complete||14/07/2022|
|Service providers have access to designated areas for the safe and hygienic storage of cleaning/laundry equipment and chemicals.||The cleaner’s trolley had open spray bottles and 750ml bottles of chemicals within reach of residents.||Ensure that chemicals are safely stored on cleaning trollies.||PA Low||Reporting Complete||14/07/2022|
|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 facility does not have a current approved fire evacuation plan.||Ensure that an approved fire evacuation plan is in place.||PA Low||Reporting Complete||14/07/2022|
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: 07 December 2021
Audit type:Certification Audit
- Ultimate Care Rose Lodge - Dec 2021 (docx, 46.76 KB)
- Ultimate Care Rose Lodge - Dec 2021 (pdf, 182.35 KB)
Audit type:Surveillance Audit
- Ultimate Care Rose Lodge - Jul 2020 (docx, 52.16 KB)
- Ultimate Care Rose Lodge - Jul 2020 (pdf, 137.07 KB)
Audit type:Partial Provisional Audit; Certification Audit
- Ultimate Care Rose Lodge - Nov 2018 (docx, 46.61 KB)
- Ultimate Care Rose Lodge - Nov 2018 (pdf, 179.85 KB)
Audit type:Provisional Audit