Victoria Epsom Rest Home
Profile & contact details
Premises name | Victoria Epsom Rest Home |
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Address | 28 Orakau Avenue Epsom Auckland 1023 |
Total beds | 24 |
Service types | Rest home care |
Certification/licence name | Victoria Epsom Limited - Victoria Epsom Rest Home |
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Current auditor | Health and Disability Auditing New Zealand Limited |
End date of current certificate/licence | 21 August 2022 |
Certification period | Other months |
Provider name | Victoria Epsom Limited |
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Street address | 28 Orakau Avenue Epsom Auckland 1023 |
Post address | 28 Orakau Avenue Epsom Auckland 1023 |
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: 22 February 2021
Outcome required | Found at audit | Action required | Risk rating | Action status | Date action reported complete |
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There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery. | Staff do not have on call access to one of the employed registered nurses between the hours of 10pm to 7am. | Provide on call access to one of the registered nurses after hours. | PA High | Reporting Complete | 19/11/2019 |
The organisation has a clearly defined and documented infection control programme that is reviewed at least annually. | The infection control programme has not been reviewed annually. | Review the infection control programme annually. | PA Low | Reporting Complete | 18/03/2020 |
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes. | There were insufficient supplies in the event of a wound or breach in skin integrity. | Ensure sufficient clinical supplies are available within the facility | PA Low | Reporting Complete | 18/03/2020 |
Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group. | The menu has not been reviewed by a registered dietician or nutritionist. | Have the menu reviewed by a registered dietician or nutritionist. | PA Low | Reporting Complete | 18/03/2020 |
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. | The storage and disposal of medications does not meet requirements. | Dispose and store medications as required. | PA Low | Reporting Complete | 18/03/2020 |
During a temporary absence a suitably qualified and/or experienced person performs the manager's role. | The service manager is not a NZ registered nurse, as required in the facility manager position description. | Ensure clinical management is delegated to a registered nurse, as per the facility management position description. | PA Moderate | Reporting Complete | 18/03/2020 |
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.
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 reports
Audit date: 22 February 2021Audit type:Surveillance Audit
- Victoria Epsom Rest Home - Feb 2021 (docx, 33.4 KB)
- Victoria Epsom Rest Home - Feb 2021 (pdf, 132.31 KB)
Audit type:Certification Audit
- Victoria Epsom Rest Home - Oct 2019 (docx, 41.95 KB)
- Victoria Epsom Rest Home - Oct 2019 (pdf, 161.57 KB)
Audit type:Surveillance Audit
- Victoria Epsom Rest Home - Aug 2018 (docx, 30.41 KB)
- Victoria Epsom Rest Home - Aug 2018 (pdf, 119.22 KB)
Audit type:Certification Audit