Waihi Hospital & Rest Home
Profile & contact details
|Premises name||Waihi Hospital & Rest Home|
|Address||18 Toomey Street Waihi 3610|
|Service types||Maternity, Medical, Rest home care, Geriatric|
|Certification/licence name||Waihi Hospital (2001) Limited - Waihi Hospital & Rest Home|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||26 March 2020|
|Certification period||36 months|
|Provider name||Waihi Hospital (2001) Limited|
|Street address||18 Toomey Street Waihi 3610|
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: 27 June 2018
|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.||Maternity: Review of the maternity medication charts showed missing documentation with regards to prescribing, dispensing and documentation requirements as follows; (a) Two of ten medication charts had no allergy noted or not; b) Two of 10 medication charts had no designation of prescriber; c) Two of ten medication charts had no frequency of medication prescribed; d) Two of ten medication charts had no route of medication prescribed; e) One of ten medication charts had no specimen signature of … (this text has been trimmed due to space limits).||Ensure all medications are prescribed correctly including the noting of allergies, correct dosage, route and frequency of medications and include prescriber’s designation and specimen signature.||PA Moderate||Reporting Complete||17/10/2018|
|Consumers have a right to full and frank information and open disclosure from service providers.||Fifteen of eighteen incident/accident forms reviewed for May 2018 were missing evidence that family were kept informed. In three instances where family notification was documented, it was written in the resident progress notes and not on the accident/incident form.||Ensure that the accident/incident forms evidence families are kept informed.||PA Low||Reporting Complete||08/10/2018|
|Key components of service delivery shall be explicitly linked to the quality management system.||The internal audit programme schedule to monitor key components of service delivery is not being completed. For 2018, nine internal audits were scheduled (year to date) but none have been completed. The internal audit schedule for 2017 indicated that internal audits ceased to take place after August 2017. Annual resident surveys were last completed, collated and analysed in 2016. The survey has not been repeated since this time. The facility manager stated that plans are in place to survey … (this text has been trimmed due to space limits).||Ensure the internal auditing schedule is implemented to monitor service delivery.||PA Low||Reporting Complete||08/10/2018|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Meeting minutes were not all available. There is a lack of evidence to suggest that quality data is collated, analysed and discussed with staff.||Ensure that quality data is collated, analysed and discussed with staff.||PA Moderate||Reporting Complete||08/10/2018|
|A process to measure achievement against the quality and risk management plan is implemented.||The quality risk management system for 2017 and 2018 is not measuring achievements or corrective actions required.||Ensure the documented quality and risk management programmes measure both achievements and areas for improvements.||PA Low||Reporting Complete||08/10/2018|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||The corrective action plan register has not been updated since January 2017.||Ensure a corrective action planning process is put back into place.||PA Low||Reporting Complete||08/10/2018|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||(i) Only three mandatory in-services have been provided in 2018 (YTD). Mandatory training around infection control indicated that only 6 of 27 staff had attended; (ii) Attendance for online education could not be assessed during the audit to determine attendance rates; (iii) The new RN’s in aged care (who provide oversite to maternity) and the two new HCA’s in maternity have not all completed maternity emergencies training i.e.: post-partum haemorrhage, neonatal CPR. (iv) Performance appraisa… (this text has been trimmed due to space limits).||(i) Ensure staff attend mandatory training to meet requirements of the aged residential care contract. (ii) Ensure records of staff completing online education are maintained. (iii) Ensure the new RN’s in aged care (who provide oversite to maternity) and the two new HCA’s in maternity have completed maternity emergencies training i.e.: post-partum haemorrhage, neonatal CPR. (iv) Ensure staff have a current performance appraisal.||PA Moderate||Reporting Complete||08/10/2018|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||Maternity: The current LMC roster did not have a named midwife for a 24-hour rostered period but does provide a list of on-call LMCs that can be called starting at the top of the list and working down until a LMC responds. If a HCA fails to get hold of a LMC they would then call 111, as stated in the ‘Waihi maternity annexe-24-hour midwifery cover’ policy statement. The service policy clearly describes the process for accessing on-call midwives. There has not been an instance in this time whe… (this text has been trimmed due to space limits).||Ensure the current on-call rostering meets the contract and is approved for Waihi maternity service. Or ensure that the current process is approved by the DHB in writing||PA Moderate||Reporting Complete||08/10/2018|
|All records are legible and the name and designation of the service provider is identifiable.||Maternity: On reviewing five sets of notes, it was evident that the documentation was signed, but no written name, designation, or sample signature provided. Drug charts also showed no name, designation or sample signature.||Ensure records include the writer’s name and designation and/or a copy of sample signatures are available for reference||PA Low||Reporting Complete||08/10/2018|
|Service providers responsible for medicine management are competent to perform the function for each stage they manage.||Aged Care/Maternity: Medication competency assessments are overdue for six of nine healthcare assistants (HCAs) and five of the six RNs. Mandatory medication training indicated that only 5 of 15 staff who administer medication attended.||Ensure medication training and medication competencies are completed annually for applicable staff||PA Moderate||Reporting Complete||08/10/2018|
|The facilitation of safe self-administration of medicines by consumers where appropriate.||Maternity: A review of ten clinical files identified self-medicating charts were not being implemented as per policy: (i)Three files had no medication chart at all, but in the clinical notes it has been documented that medication was taken by each woman, (ii) Four files had a self-medicating consent form to be signed by the woman, that were not signed.||Maternity:(i)-(ii)Ensure every client has a self-medicating chart if requiring medication, and that all self-medicating charts are fully completed and reflect current legislation and guidelines.||PA Moderate||Reporting Complete||08/10/2018|
|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.||Aged Care: Two of two ARC long-term residents (rest home and hospital) did not have interRAI assessments.||Ensure interRAI assessments are completed for all long-term care residents.||PA Moderate||Reporting Complete||08/10/2018|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Maternity: (i)Five sets of clinical notes were reviewed. All five files had minimal interventions documented in the care plans by the LMCs to support all levels of care required for the mother and baby. There was a form where a plan could be documented, but where this was completed, and the instructions were very brief and generic. (ii) Not every set of notes had a care plan. (iii) One birth at Waihi had no delivery summary in the clinical notes. There was no daily update to the care plans… (this text has been trimmed due to space limits).||Maternity: Ensure LMCs provide clear and concise care plans for each of their clients and her baby. Ensure a labour/birth and infant summary is kept in the client records; and ensure daily updates to the postnatal care plan are documented.||PA Moderate||Reporting Complete||08/10/2018|
|Service delivery plans demonstrate service integration.||Maternity: While the verbal communication between the LMCs and HCAs is in place (as per interviews); the written communication is lacking. Care plans did not include support needed around breastfeeding, education, referrals or discharge procedures. Clinical records (progress notes) did not always include informed consent discussions, daily discussions between mother, LMC and HCA and deviation from the care plan. LMC’s visited their client each day and write in the notes, but there was little… (this text has been trimmed due to space limits).||Maternity: Ensure care plans include support needed around breastfeeding, education, referrals or discharge procedures. Ensure daily progress notes identify the care provided (including deviations from the care plan) and progress of the mother and baby. Ensure daily progress notes include discussions, evaluations, referrals and discharge planning.||PA Moderate||Reporting Complete||08/10/2018|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||Maternity: The client interviewed stated she completed a breastfeeding record sheet. However, there was no evidence of this in the clinical notes, or any of the five clinical notes reviewed. There were no discharge plans for the mother and her baby documented.||Maternity: Ensure clinical records include breastfeeding records and discharge plans.||PA Moderate||Reporting Complete||08/10/2018|
|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.||Aged Care: Four out of four short-term care plans reviewed did not document evaluation of progress towards the desired goal or had not been signed off when resolved.||Aged Care: Ensure short-term care plans are evaluated to monitor progress towards the desired goal and are signed off by a RN when resolved.||PA Moderate||Reporting Complete||08/10/2018|
|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.||Aged Care: Eye-drops are not being dated when opened. Maternity: (i)Six of 10 medication records had missing documentation in regard to prescribing, administering and signing of the medications. (ii) One medication chart had an allergy noted, the remaining charts had no documentation. One booking and admission form had an allergy noted, but this was not indicated on the medication chart. (iii) There is no specific place in the woman’s room where her medication can be stored safely. (iv) The … (this text has been trimmed due to space limits).||Aged Care: Ensure eye-drops are dated when opened. Maternity: (i) -(iii)Ensure all medications are prescribed correctly, including the noting of allergies, prescribers full signature, full name written clearly and designation. (iv) Ensure client rooms have a safe place to store medication while an in-patient. (v) Ensure the medication chart is easy to follow for the prescriber||PA Moderate||Reporting Complete||08/10/2018|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||Aged Care: The activities coordinator only works three days a week. Although there are volunteers there are very few planned activities in the hospital due to time constraints. There is no documented hospital activities programme. Hospital residents do not have van outings.||Aged Care: Ensure more hours are allocated to hospital activities and that there is a documented hospital activities programme including van outings.||PA Low||Reporting Complete||17/10/2018|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||The current LMC roster did not have a named midwife for a 24-hour rostered period but does provide a list of on-call LMCs that can be called starting at the top of the list and working down until a LMC responds. If a HCA fails to get hold of a LMC they would then call 111, as stated in the ‘Waihi maternity annexe-24 hour midwifery cover’ policy statement. The service policy clearly describes the process for accessing on-call midwives. Management stated there has not been a time when the on-cal… (this text has been trimmed due to space limits).||Ensure the current on-call rostering meets the contract and is approved for Waihi maternity service.||PA Low||Reporting Complete||17/10/2018|
|The facilitation of safe self-administration of medicines by consumers where appropriate.||Maternity: Review of the maternity medication charts showed missing documentation with regards to prescribing, dispensing and documentation requirements as follows: (a) Two of ten files reviewed did not have a self-medication chart in the client file but it was identified that the client was self-medicating; (b) Two of ten self-medication charts had no strength of medication documented; (c) Two of ten self-medication charts had client identifiers but no medications documented on them, within t… (this text has been trimmed due to space limits).||(a-e) Ensure that self-medication charts are fully completed and reflect current legislation and guidelines.||PA Moderate||Reporting Complete||24/11/2018|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Rest home and hospital; Two hospital and one rest home resident file did not evidence that care plan interventions provided sufficient detail to guide care staff. Maternity Five of five maternity files reviewed; a) did not include a labour/birth and infant summary enclosed; and b) did not identify daily updates to the postnatal care plan.||Rest home and hospital: Ensure that long-term care plans document sufficient intervention detail relating to diabetes management, medication management and weight loss. Maternity (a-b) Ensure all documentation meets facility and legal requirements. Include dietary requirements to the postnatal care plan.||PA Moderate||Reporting Complete||24/11/2018|
|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.||Two of four short-term care plans reviewed did not document evaluation of progress towards the desired goal and two had not been signed off when resolved.||Ensure short-term care plans are evaluated to monitor progress towards the desired goal and are signed off by a registered nurse when resolved.||PA Low||Reporting Complete||24/11/2018|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||i) On-line training has not been embedded into practice with low attendance rates. ii) The designated health and safety officer has not attended any formal health and safety training. iii) Cultural training has not been provided for staff. iv) InterRAI assessments are behind schedule due to a lack of RN accessibility to InterRAI training.||i) Ensure staff complete all online education and training topics that are required. ii) Ensure the health and safety officer attends external health and safety training. iii) Ensure cultural training is included in the annual education and training plan. iv) Ensure there are adequate numbers of InterRAI trained RNs.||PA Low||Reporting Complete||24/11/2018|
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: 27 June 2018
Audit type:Surveillance Audit
- Waihi Hospital & Rest Home - Jun 2018 (docx, 42.96 KB)
- Waihi Hospital & Rest Home - Jun 2018 (pdf, 168.72 KB)
Audit type:Certification Audit
- Waihi Hospital & Rest Home - Jan 2017 (docx, 51.01 KB)
- Waihi Hospital & Rest Home - Jan 2017 (pdf, 199.11 KB)
Audit type:Surveillance Audit
- Waihi Hospital & Rest Home - Apr 2016 (docx, 38.28 KB)
- Waihi Hospital & Rest Home - Apr 2016 (pdf, 150.68 KB)
Audit type:Certification Audit
- Waihi Hospital & Rest Home - Jan 2015 (docx, 67.68 KB)
- Waihi Hospital & Rest Home - Jan 2015 (pdf, 193.26 KB)
Audit type:Surveillance Audit