Wesley Home and Care
Profile & contact details
| Premises name | Wesley Home and Care |
|---|---|
| Address | 227 Mount Eden Road Mount Eden Auckland 1024 |
| Total beds | 26 |
| Service types | Rest home care |
| Certification/licence name | Victoria Mt Eden Limited - Wesley Home and Care |
|---|---|
| Current auditor | The DAA Group Limited |
| End date of current certificate/licence | 20 November 2024 |
| Certification period | 12 months |
| Provider name | Victoria Mt Eden Limited |
|---|---|
| Street address | Wesley 227 Mount Eden Road Mount Eden Auckland 1024 |
| Post address | 227 Mount Eden Road Mount Eden Auckland 1024 |
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: 18 October 2023
| Outcome required | Found at audit | Action required | Risk rating | Action status | Date action reported complete |
|---|---|---|---|---|---|
| Service providers shall ensure that people, visitors and the workforce (both paid and unpaid) are protected from harm when handling waste or hazardous substances. | A hazardous substances register has not been developed. Staff have not been employed and training related to the safe management of waste and hazardous substances has not occurred. | Develop a hazardous substances register specific to Wesley Home and ensure all people are protected from harm when handling waste or hazardous substances. | PA Low | In Progress | |
| Governance bodies shall ensure service providers deliver services that improve outcomes and achieve equity for Māori. | There are policies but no residents, and the service provider is unable to demonstrate how they will improve outcomes and achieve equity for Māori. | Establish methods for ensuring that services improve outcomes and achieve equity for Māori. | PA Low | In Progress | |
| Service providers shall implement systems to determine and develop the competencies of health care and support workers to meet the needs of people equitably. | The cultural make-up of the workforce and the percentage of staff that have completed cultural competency training has not been determined. | Implement systems to determine and develop the competencies of staff to meet the needs of residents equitably. Ensure that all staff are regularly provided opportunities to learn and understand how to meet the needs of people equitably, and that competency records for all health care and support workers are maintained. | PA Low | In Progress | |
| Governance bodies shall ensure service providers deliver services that improve outcomes and achieve equity for tāngata whaikaha people with disabilities. | There are policies but no residents, therefore the service provider is unable to demonstrate service delivery that improves outcomes and achieves equity for tāngata whaikaha. | Establish methods for ensuring that services improve outcomes and achieve equity for tāngata whaikaha. | PA Low | In Progress | |
| Service providers shall assist with training and support for people and service providers to maximise people and whānau receiving services participation in the service. | There are no staff, activities or methods yet established to maximise resident and whānau participation in the service. | Ensure staff have knowledge and resources to support resident involvement and participation in service delivery. | PA Low | In Progress | |
| People and whānau shall have the opportunity to be involved in preparation of food as appropriate to the service. | The service cannot demonstrate attainment because there were no residents on site. | Ensure residents and their whanau are provided with opportunities to be involved in food preparation if they desire. | PA Low | In Progress | |
| Governance bodies shall support people receiving services and whānau to participate in the planning, implementation, monitoring, and evaluation of service delivery. | There are policies but no residents or services being delivered yet. Evidence of resident and whanau participation could not be demonstrated. | Ensure that people receiving services and their families are given opportunities to participate in the planning, implementation, monitoring, and evaluation of service delivery. | PA Low | In Progress | |
| Service providers shall establish environments that encourage collecting and sharing of high-quality Māori health information. | There are no staff, or methods yet established for the collection and sharing of high-quality Māori health information. | Encourage staff to participate in learning opportunities that provide them with the most recent literature on Māori health outcomes and disparities, health equity, and quality. | PA Low | In Progress | |
| Service providers shall ensure people’s dining experience and environment is safe and pleasurable, maintains dignity and is appropriate to meet their needs and cultural preferences. | The service cannot demonstrate attainment because there were no residents on site. | Ensure residents are provided with a safe, comfortable and pleasurable dining experience in ways that maintains their dignity and meets their unique needs and cultural preferences. Ensure there is suitable refrigeration and storage for food and adequate cleaning and sanitation for used crockery and cutlery | PA Low | In Progress | |
| Service providers, shall evaluate the effectiveness of their AMS programme by: (a) Monitoring the quality and quantity of antimicrobial prescribing, dispensing, and administration and occurrence of adverse effects; (b) Identifying areas for improvement and evaluating the progress of AMS activities. | Service delivery has not commenced and the methods for monitoring antimicrobial prescribing, dispensing, administration and occurrence of adverse events cannot be demonstrated. | Ensure the effectiveness of the AMS is evaluated. | PA Low | In Progress | |
| Governance bodies shall have meaningful Māori representation on relevant organisational boards, and these representatives shall have substantive input into organisational operational policies. | The directors have not yet established links or relationships with local iwi, or determined how they will meet this requirement. | Ensure there is meaningful Māori representation and input into organisational policies and processes. | PA Low | In Progress | |
| Service providers shall ensure there are implemented fire safety and emergency management policies and procedures identifying and minimising related risk. | The fire safety and emergency policies and procedures need to be reviewed and implemented. | Ensure that the fire safety and emergency management policies and procedures identify all risks related to the site and these are implemented. | PA Low | Reporting Complete | 24/11/2023 |
| Service providers shall invest in the development of organisational and health care and support worker health equity expertise. | Staff are yet to be employed. Systems for staff education and development of care staff health equity expertise are not established. | Ensure that the directors and staff engage in opportunities to develop health equity expertise. | PA Low | In Progress | |
| Results of surveillance and recommendations to improve performance where necessary shall be identified, documented, and reported back to the governance body and shared with relevant people in a timely manner. | The processes for conducting surveillance of HAI, and reporting results have not been implemented as service delivery has not commenced, | Ensure that results of infection surveillance are documented and reported to staff, directors and other relevant people in a timely manner. | PA Low | In Progress | |
| Service providers shall ensure that the environment is clean and there are safe and effective cleaning processes appropriate to the size and scope of the health and disability service that shall include: (a) Methods, frequency, and materials used for cleaning processes; (b) Cleaning processes that are monitored for effectiveness and audit, and feedback on performance is provided to the cleaning team; (c) Access to designated areas for the safe and hygienic storage of cleaning equipment and chemi… (this text has been trimmed due to space limits). | The monitoring for effectiveness of cleaning services cannot be demonstrated as service delivery has not commenced and staff are not employed. | Ensure that environmental cleaning occurs daily, and that the effectiveness of cleaning processes is monitored. | PA Low | In Progress | |
| Health care and support workers shall have the opportunity to be involved in a debrief and discussion, and receive support following incidents to ensure wellbeing. | Methods for supporting staff following significant incidents have not been implemented as service delivery has not commenced. | Ensure that staff who are directly or indirectly involved in significant incidents are provided opportunities to receive support that protects and promotes their wellbeing. | PA Low | In Progress | |
| Service providers shall ensure there are safe and effective laundry services appropriate to the size and scope of the health and disability service that include: (a) Methods, frequency, and materials used for laundry processes; (b) Laundry processes being monitored for effectiveness; (c) A clear separation between handling and storage of clean and dirty laundry; (d) Access to designated areas for the safe and hygienic storage of laundry equipment and chemicals. This shall be reflected in a writt… (this text has been trimmed due to space limits). | The monitoring for effectiveness of laundry services cannot be demonstrated as service delivery has not commenced and staff are not employed. | Ensure that that the effectiveness of the laundry service is monitored. | PA Low | In Progress | |
| Service providers adopt a holistic approach to menu development that ensures nutritional value, respecting and supporting cultural beliefs, values, and protocols around food. Māori and whānau shall have menu options culturally specific to te ao Māori. | There are no residents. The prospective service provider cannot demonstrate they meet the requirements of this criterion. | Ensure Māori residents are offered menu options that are culturally specific to their preferences. | PA Low | In Progress | |
| Service providers shall provide appropriate support, advice, and treatment for Māori. | The prospective provider cannot demonstrate this as there are no residents. | Provide appropriate support, advice and treatment for Māori residents when and if required. | PA Low | In Progress | |
| Service providers shall provide educational resources that are available in te reo Māori and are accessible and understandable for Māori accessing services. | Educational material and resources related to infection control were not on site. | Ensure that infection control educational resources are available in te reo Māori and other languages to promote resident understanding. | PA Low | In Progress | |
| IP personnel and committees shall participate in partnership with Māori for the protection of culturally safe practice in IP, and thus acknowledge the spirit of Te Tiriti. | Access to advice and information related to the protection of culturally safe IP practice is available but has not been accessed. | Ensure the IPC understands and incorporates culturally safe practice in IP processes. | PA Low | In Progress | |
| Governance bodies shall have demonstrated expertise in Te Tiriti, health equity, and cultural safety as core competencies. | The directors cannot demonstrate expertise in health equity, Te Tiriti and cultural safety. | Ensure the directors develop knowledge and expertise in Te Tiriti, health equity and cultural safety by completing relevant education and training. | PA Low | In Progress | |
| There shall be a clinical governance structure in place that is appropriate to the size and complexity of the service provision. | An appropriate (suitable for size and complexity) clinical governance structure has not been established as service delivery has not commenced. | Ensure there are methods for clinicians, managers and other staff to work together to improve and be held accountable for the quality and safety of the health and disability services they provide. | PA Low | In Progress | |
| Infection prevention education shall be provided to health care and support workers and people receiving services by a person with expertise in IP. The education shall be: (a) Included in health care and support worker orientation, with updates at defined intervals; (b) Relevant to the service being provided. | Information about infection prevention at orientation and the provision of ongoing staff education cannot be demonstrated, as no health care staff have been employed. | Ensure staff complete IP and AMS education as part of their orientation and attend updates at a frequency determined by the annual staff training plan or more frequently when required. | PA Low | Reporting Complete | 24/11/2023 |
| Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services. | No care staff or allied health staff (for example, housekeeping) have been employed. | Ensure there are sufficient staff on duty 24/7 to provide clinically and culturally safe services commensurate to the needs and number of residents on site. | PA Low | Reporting Complete | 24/11/2023 |
| Service providers shall ensure their health care and support workers have the skills, attitudes, qualifications, experience, and attributes for the services being delivered. | No care staff or allied health staff (for example, housekeeping) have been employed. | Ensure that all staff recruited and employed have the right skills, attributes, attitudes, qualifications and experience to deliver rest home level care. | PA Low | Reporting Complete | 24/11/2023 |
| Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided. | There are no care staff employed. Orientation to the building layout, emergency procedures and other essential information has not commenced. | Ensure all staff complete orientation and induction to the building layout, emergency procedures and other essential information. | PA Low | Reporting Complete | 24/11/2023 |
| A medication management system shall be implemented appropriate to the scope of the service. | The fit out of the designated medication room and installation of an electronic medicines system has not been completed. | Ensure that the designated medicines room is completed, that the software required for holding current medication information is installed and that all other components required for a safe and effective medication management system are implemented. | PA Low | Reporting Complete | 24/11/2023 |
| The following aspects of the system shall be performed and communicated to people by registered health professionals operating within their role and scope of practice: prescribing, dispensing, reconciliation, and review. | All aspects of a safe system for medication prescribing, dispensing, reconciliation and review could not be demonstrated as service delivery has not commenced. | Ensure all stages of the medicines management system are performed by health professionals (for example, the prescribing GP, dispensing pharmacist and RN overseeing the system) who are operating within their role and scope of practice. | PA Low | Reporting Complete | 24/11/2023 |
| Service providers ensure competent health care and support workers manage medication including: receiving, storage, administration, monitoring, safe disposal, or returning to pharmacy. | The competency of health care staff to safely manage medication cannot be demonstrated as service delivery has not commenced and no staff are employed. | Ensure that the health care staff who will be directly involved in medicines management are assessed as competent and understand their responsibilities prior to administering medicines to residents. This includes accurate recording of medicines administered, and the monitoring and reporting of medication effects. | PA Low | Reporting Complete | 24/11/2023 |
| A process shall be implemented to identify, record, and communicate people’s medicinerelated allergies or sensitivities and respond appropriately to adverse events. | The process for effectively managing and/or responding to people’s medicine related allergies or sensitivities cannot be demonstrated as service delivery has not commenced. | Ensure that processes for effectively managing and responding to people’s medicine related allergies or sensitivities are known and implemented. | PA Low | Reporting Complete | 24/11/2023 |
| Buildings, plant, and equipment shall be fit for purpose, and comply with legislation relevant to the health and disability service being provided. The environment is inclusive of peoples’ cultures and supports cultural practices. | Not all equipment was on site, or all amenities installed. Testing and tagging in accordance with in-service safety inspection and testing of electrical equipment, Australian and New Zealand Standard AS/NZS 3760:2010 has not occurred. The sluice room and laundry required completion and hot water testing was not occurring. | Ensure that the building, plant and equipment are maintained as fit for purpose and comply with relevant legislation and guidance standards. Ensure that all amenities are in place, such as a functional and fully equipped sluice room, fitted out bathrooms and laundry, and hot water temperature testing is occurring. | PA Low | Reporting Complete | 24/11/2023 |
| Service providers will explain emergency and security arrangements to all people using the services. | Emergency and security arrangements cannot be explained to all people using the services as there are no residents and service delivery has not commenced. | Ensure residents are informed about emergency and security arrangements and have consented to the use of CCTV. | PA Low | Reporting Complete | 24/11/2023 |
| Health care and support workers shall receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures. | Staff training in use of equipment and how to respond to fire and emergency situations including security situations, has not occurred. A plan is in place for undertaking trial evacuations but there are no staff. All care staff, activities and other staff engaging directly with residents require current first aid certificates. | Ensure all staff are first aid certificated, receive appropriate information and training to respond to emergency and security situations and that they have attended at least one trial evacuation on site. | PA Low | Reporting Complete | 24/11/2023 |
| Based on prescriber instructions, service providers shall provide ongoing support for people’s understanding of their medication. | Service delivery has not commenced. There are no staff or residents to demonstrate that people are supported in understanding the medicines they are taking. | Ensure staff support residents in understanding their medication. | PA Low | Reporting Complete | 21/12/2023 |
| Service providers shall ensure there is a system to identify, plan, facilitate, and record ongoing learning and development for health care and support workers so that they can provide high-quality safe services. | Staff are yet to be employed. Systems for staff education and professional development are not established. | Implement systems to identify, plan, facilitate and record ongoing learning and development of staff. | PA Low | Reporting Complete | 20/12/2023 |
| Information held about health care and support workers shall be accurate, relevant, secure, and confidential. Ethnicity data shall be collected, recorded, and used in accordance with Health Information Standards Organisation (HISO) requirements. | There are no current staff records, and the system for holding staff information is not yet implemented. | Ensure a system for holding accurate, relevant staff information is implemented and kept secure and confidential. Ensure that staff ethnicity data is recorded. | PA Low | Reporting Complete | 20/12/2023 |
| Over-the-counter medication and supplements shall be considered by the prescriber as part of the person’s medication. | Consideration and use of over-the-counter medicines and supplements for residents cannot be demonstrated until service delivery commences. | Ensure that prescribers take into consideration over-the-counter medication and supplements as part of each resident’s medication regime. | PA Low | Reporting Complete | 21/12/2023 |
| Governance bodies shall appoint a suitably qualified or experienced person to manage the service provider with authority, accountability, and responsibility for service provision. | The facility manager needs to develop skills and knowledge related to management of a residential aged care service. | Ensure the facility manager fully understands all the contractual, legislative and regulatory requirements for managing a residential aged care facility. Ensure the manager attends at least eight hours of professional development related to the role annually. | PA Low | Reporting Complete | 20/02/2024 |
| Support systems promote health care and support worker wellbeing and a positive work environment. | There are no staff, or methods yet established to promote staff wellbeing and a positive work environment. | Implement systems that promote staff wellbeing and a positive work environment. | PA Low | Reporting Complete | 20/02/2024 |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | No care staff are currently employed, and performance appraisals are not yet due. | Ensure staff performance is reviewed and discussed according to the timeframes outlined in your policies and procedures. | PA Low | Reporting Complete | 20/02/2024 |
| Where required by legislation, there shall be a Fire and Emergency New Zealand- approved evacuation plan. | The evacuation plan has been submitted but approval by Fire and Emergency New Zealand has not been received. | Provide evidence of a Fire and Emergency New Zealand- approved evacuation plan. | PA Low | Reporting Complete | 20/02/2024 |
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: 18 October 2023Audit type:Partial Provisional Audit