Profile & contact details
|Premises name||Warkworth Hospital|
|Address||31 Blue Gum Drive Warkworth 0910|
|Service types||Rest home care, Geriatric, Medical|
|Certification/licence name||Warkworth Hospital Limited - Warkworth Hospital|
|Current auditor||Health Audit (NZ) Limited|
|End date of current certificate/licence||30 July 2018|
|Certification period||36 months|
|Provider name||Warkworth Hospital Limited|
|Street address||31 Blue Gum Drive Warkworth 0910|
|Post address||P O Box 650 Warkworth 0941|
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: 23 January 2017
|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.||Six of the 10 medications charts had evidence of transcribing.||Provide evidence that medications are not transcribed.||PA Moderate||Reporting Complete||22/08/2017|
|The use of enablers shall be voluntary and the least restrictive option to meet the needs of the consumer with the intention of promoting or maintaining consumer independence and safety.||There is no documentation in relation to enabler use and the register does not record current enablers in use.||Provide evidence of documentation relating to enablers and current register of enablers used at the facility.||PA Low||Reporting Complete||29/02/2016|
|The needs, outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning.||i)Initial care plans were not developed on admission. ii)Long term care plans were not comprehensive and did not reflect all assessment information. iii)Four residents did not have the required risk assessments completed on admission. iv)Four clinical files did not include documented assessment outcomes or short term care plans to reflect assessed needs. v)There was no documented evidence that residents or family had been involved in the development of care plans. vi)Three clinical files identif… (this text has been trimmed due to space limits).||i)Develop initial care plans on admission. ii)Ensure initial and long term care plans reflect all aspects of assessment information. iii)Ensure ongoing assessment information is documented and short term care plans are developed where progress is different from expected. iv)Document evidence that resident or family have been involved in the development of initial and long term care plans. v)Document discussions held with family to demonstrate information sharing on an ongoing basis including six… (this text has been trimmed due to space limits).||PA Moderate||Reporting Complete||29/02/2016|
|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)Nurses were transcribing medications. ii)Medications to use as required did not consistently have documented indications for use. iii)There were no specimen signatures for prescribing doctors. iv)Staff did not follow correct medication administration procedure.||i)Nurses are not to transcribe medications. ii)The prescribing doctor must provide indications for use for medications to use as required. iii)Record specimen signatures for prescribing doctors. iv)Staff to follow correct medication administration procedure.||PA Moderate||Reporting Complete||29/02/2016|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||Competency assessments for restraint were not available for clinical staff.||Provide evidence that clinical staff complete competency assessments for restraint and that the competencies remain current.||PA Low||Reporting Complete||29/02/2016|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Corrective action plans are inconsistently developed, implemented, monitored and evaluated to address areas requiring improvement as a result of issues raised on RN, staff and resident meetings.||Provide evidence that corrective action plans are being developed implemented, monitored and reviewed to address areas requiring improvement as a result of issues raised at RN, staff and resident meetings.||PA Moderate||Reporting Complete||29/02/2016|
|The service respects the physical, visual, auditory, and personal privacy of the consumer and their belongings at all times.||A resident’s frequent disruptive behaviour is having an effect on other residents and staff.||Provide evidence that this resident is reassessed with a view to being placed appropriately.||PA Low||Reporting Complete||29/02/2016|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Quality improvement data apart from infection prevention and control data is not being analysed to identify trends.||Provide evidence that all quality improvement data is analysed to identify trends and is communicated back to staff.||PA Moderate||Reporting Complete||28/06/2016|
|The organisation has a quality and risk management system which is understood and implemented by service providers.||The audit programme does not include all areas of service delivery. Completed audits are not consistently completed fully.||Provide evidence that the audit programme includes all necessary audits; that audits are completed as per the programme and that documentation is fully completed and dates and times recorded.||PA Moderate||Reporting Complete||28/06/2016|
|The organisation has a clearly defined and documented infection control programme that is reviewed at least annually.||There has not been an annual review of the infection control programme.||Complete an annual review of the infection control programme.||PA Low||Reporting Cancelled||17/02/2016|
|Service providers responsible for medicine management are competent to perform the function for each stage they manage.||A current medication competency was not sighted for all staff that assist in medication management.||Provide evidence that all staff who assist in medication management are assessed as competent to perform their role.||PA Moderate||Reporting Complete||22/08/2017|
|The needs, outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning.||Three of the five resident files sampled did not have long term care plans that recorded all the residents identified needs, goals and interventions. Four of the five care plans sampled did not cover all aspects of the resident’s assessed physical, psychosocial, spiritual and cultural abilities, deficits, and needs;||Provide evidence that the long term care plans identify all the residents’ needs that have been identified through the assessment process. Ensure care plans cover all required aspects, as per contract requirements.||PA Moderate||Reporting Complete||22/08/2017|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||Individual staff education records have not been maintained. The length of time for educational sessions is not consistently recorded. Annual staff appraisals are not up to date for any of the staff files sampled.||Maintain individual staff education records, including the length of time for each education session. Conduct annual performance appraisals as required.||PA Low||Reporting Complete||21/02/2018|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Corrective actions are consistently developed but they are not always evaluated to show the outcome and if a service improvement was achieved.||Provide evidence that all corrective actions are evaluated to show outcome results.||PA Low||Reporting Complete||21/02/2018|
|There is a document control system to manage the policies and procedures. This system shall ensure documents are approved, up to date, available to service providers and managed to preclude the use of obsolete documents.||Not all policies and procedures have been reviewed within the organisations required timeframes.||Provide evidence that all policies and procedures have been updated to meet identified timeframes and to reflect current good practice and legislative requirements.||PA Low||Reporting Complete||21/02/2018|
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: 23 January 2017
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit