Whangaroa Health Services
Profile & contact details
|Premises name||Whangaroa Health Services|
|Address||180 Omaunu Road RD 2 Kaeo 0479|
|Service types||Geriatric, Medical, Rest home care|
|Certification/licence name||Whangaroa Health Services Trust - Whangaroa Health Services|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||01 June 2024|
|Certification period||36 months|
|Provider name||Whangaroa Health Services Trust|
|Street address||180 Omaunu Road RD2 Kaeo 0479|
|Post address||PO Box 64 Kaeo 0448|
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 October 2022
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|All records pertaining to individual consumer service delivery are integrated.||Four of five resident file reviewed did not contain medical notes from GP reviews.||Ensure all records pertaining to individual consumer service are integrated.||PA Moderate||Reporting Complete||15/08/2022|
|Service providers follow a documented process for the safe and appropriate storage and disposal of waste, infectious or hazardous substances that complies with current legislation and territorial authority requirements.||The new sluice doors did not have locks fitted on the day of audit. A cleaner’s trolley containing cleaning chemicals was readily accessible in the open, non-lockable sluice room.||Ensure all chemicals are stored safely in a manner not accessible to residents and visitors.||PA Low||Reporting Complete||15/08/2022|
|All buildings, plant, and equipment comply with legislation.||(i). The service does not have a current BWOF. (ii). The smoke doors do not comply with the current fire service evacuation plan.||(i)-(ii). Ensure the building complies with current legislation.||PA Moderate||Reporting Complete||15/08/2022|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Three of six staff files were missing evidence of a completed orientation programme.||Ensure documentation is held to evidence staff completing an orientation programme.||PA Low||Reporting Complete||26/04/2023|
|The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk.||Two of three unwitnessed falls with associated neurological observations did not follow the RN protocol.||Ensure all unwitnessed falls follow written protocol for neurological observations.||PA Low||Reporting Complete||26/04/2023|
|Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include: (a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk; (b) A process that addresses/treats the risks associated with service provision is developed and im… (this text has been trimmed due to space limits).||The hazard register, and associated environmental audit, are overdue for monitoring and review with the last review taking place over one year ago.||Ensure hazards are regularly monitored to ensure that hazards are either eliminated, isolated or minimised.||PA Low||Reporting Complete||26/04/2023|
|Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services.||There are insufficient registered nurses to provide RN cover 24/7 safely.||The service considers the number of hospital level residents receiving care so that there is sufficient RN cover or, the service seeks a dispensation in relation to the requirement to provide 24/7 RN cover from Te Whatu Ora Te Tai Tokerau.||PA Low||In Progress|
|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.||Two of five resident files showed long-term care plans and interRAI assessments were not reviewed within the timeframes stated in policy.||Ensure all interRAI assessments and care plans are reviewed within the required timeframes according to policy.||PA Low||Reporting Complete||06/11/2023|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||i) The auditor was unable to evidence that care staff have attended a minimum of eight hours of training over the past 12 months. Staff interviewed confirmed that they are reluctant to use the online education programme that has been made available to them. ii) Three of six RNs have evidence of current first aid/CPR certificates which leaves the facility short of an individual with a current CPR certificate 24/7 and on outings.||i) Ensure that staff attend a minimum of eight hours of training per year. ii) A person trained in first aid/CPR must be available 24/7 and on outings.||PA Moderate||Reporting Complete||06/11/2023|
|Service providers shall engage with people receiving services to assess and develop their individual care or support plan in a timely manner. Whānau shall be involved when the person receiving services requests this.||i). Twelve interRAI assessments are overdue for review with timeframes ranging from 10 to 221 days. ii). Three long-term care plans were not reviewed six-monthly. iii). Three long-term care plans were not consistently reviewed following interRAI reassessments.||i). & ii). Ensure interRAI assessments and long-term care plans are completed six-monthly as per contractual requirements. iii). Ensure interRAI assessments are completed prior to the care plan review.||PA Moderate||Reporting Complete||06/11/2023|
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: 27 October 2022
Audit type:Surveillance Audit
- Whangaroa Health Services - Oct 2022 (docx, 52.86 KB)
- Whangaroa Health Services - Oct 2022 (pdf, 166.39 KB)
Audit type:Partial Provisional Audit; Certification Audit
- Whangaroa Health Services - Mar 2021 (docx, 48.4 KB)
- Whangaroa Health Services - Mar 2021 (pdf, 186.86 KB)
Audit type:Surveillance Audit
- Whangaroa Health Services - Aug 2019 (docx, 33.87 KB)
- Whangaroa Health Services - Aug 2019 (pdf, 131.97 KB)
Audit type:Surveillance Audit
- Whangaroa Health Services - Sep 2018 (docx, 35.73 KB)
- Whangaroa Health Services - Sep 2018 (pdf, 139.77 KB)
Audit type:Certification Audit