Whitby Rest Home and Hospital

Profile & contact details

Premises details
Premises name	Whitby Rest Home and Hospital
Address	4 Observatory Close Whitby Porirua 5024
Total beds	101
Service types	Rest home care, Psychogeriatric, Geriatric, Medical, Dementia care

Certification/licence details
Certification/licence name	Bupa Care Services NZ Limited - Whitby Rest Home and Hospital
Current auditor	Health and Disability Auditing New Zealand Limited
End date of current certificate/licence	16 November 2025
Certification period	36 months

Provider details
Provider name	Bupa Care Services NZ Limited
Street address	Level 2 109 Carlton Grove Road Newmarket Auckland 1023
Post address	PO Box 113054 Newmarket Auckland 1149
Website	www.bupa.co.nz/

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: 20 February 2024

Outcome required	Found at audit	Action required	Risk rating	Action status	Date action reported complete
Governance bodies shall ensure compliance with legislative, contractual, and regulatory requirements with demonstrated commitment to international conventions ratified by the New Zealand government.	Measurable and specific annual facility goals have not been developed.	Ensure measurable facility goals are developed each year and regularly reviewed.	PA Low	Reporting Complete	11/09/2023
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.	i). One of seventeen caregiver staff who has worked in the dementia unit for over eighteen months has not completed their required Careerforce dementia qualification. ii). Four of fifteen caregivers who work in the PG unit have not completed the required PG Careerforce unit standards. iii). Three of the four staff have been employed to work in PG for over eighteen months.	i). – iii). Ensure staff working in either the dementia unit or the PG unit complete all required Careerforce qualifications as per Te Whatu Ora Capital, Coast contractual requirements.	PA Low	Reporting Complete	11/09/2023
Alternative essential energy and utility sources shall be available, in the event of the main supplies failing.	The stored water for an emergency is not sufficient for 20 litres per person per day for seven days, as required by the Wellington region civil defence guidelines.	Ensure sufficient water is stored.	PA Moderate	Reporting Complete	27/09/2023
Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care.	(i). Meetings have not been completed as per the annual schedule. (ii). There is no evidence of corrective actions being followed up and signed off in the meeting minutes.	Ensure that corrective actions identified in monthly quality meetings and staff meetings, are followed up and sign off as completed.	PA Low	In Progress
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). One initial assessment and care summary for a respite resident in the dementia unit was completed on day eight following admission. (ii). One initial interRAI assessment was completed six weeks after the resident commenced permanent placement. (iii). One initial long-term care plan was completed six weeks after the resident commenced permanent placement. (iv). InterRAI reassessments were not completed six-monthly for four of four resident files where this was required. (v). Six-monthly ca… (this text has been trimmed due to space limits).	(i-v). Ensure that all assessments care planning and reviews are completed in line with policy and legislative requirements.	PA Low	In Progress
Service providers shall ensure their health care and support workers have the skills, attitudes, qualifications, experience, and attributes for the services being delivered.	i). Two of seventeen caregivers who have worked in the dementia unit for over eighteen months have not completed the required Careerforce dementia standards qualification.	i). – ii). Ensure staff working in either the dementia unit or the PG unit complete all required Careerforce qualifications as per Te Whatu Ora - Capital, Coast and Hutt Valley contractual requirements.	PA Moderate	In Progress
A medication management system shall be implemented appropriate to the scope of the service.	(i). Medication room temperatures are not consistently recorded in the rest home and dementia communities. (ii). Medication room temperatures recorded above 25 degrees in the psychogeriatric community did not evidence corrective actions have been implemented. (iii). Expired midazolam was evidenced in current use in the hospital and dementia communities. (iv). The controlled drug register in the psychogeriatric and dementia communities did not evidence weekly drug checks had been completed as sch… (this text has been trimmed due to space limits).	(i). Ensure that medication room temperature monitoring is consistently recorded. (ii). Ensure corrective actions are implemented when temperatures are above maximum ranges. iii). Ensure expired medications are discarded as per legislative requirements. (iv). Ensure controlled drugs medications are checked weekly.	PA Moderate	In Progress
Fundamental to the development of a care or support plan shall be that: (a) Informed choice is an underpinning principle; (b) A suitably qualified, skilled, and experienced health care or support worker undertakes the development of the care or support plan; (c) Comprehensive assessment includes consideration of people’s lived experience; (d) Cultural needs, values, and beliefs are considered; (e) Cultural assessments are completed by culturally competent workers and are accessible in all settin… (this text has been trimmed due to space limits).	(i). One psychogeriatric resident assessed with behavioural challenges, mobility requirements, pain and falls did not evidence interventions to manage the risks. (ii). One hospital resident assessed with ongoing pain had insufficient interventions documented to guide staff in management.	(i).-(ii). Ensure care plans have detailed interventions documented to provide guidance to staff on care management.	PA Moderate	In Progress
In implementing care or support plans, service providers shall demonstrate: (a) Active involvement with the person receiving services and whānau; (b) That the provision of service is consistent with, and contributes to, meeting the person’s assessed needs, goals, and aspirations. Whānau require assessment for support needs as well. This supports whānau ora and pae ora, and builds resilience, self-management, and self-advocacy among the collective; (c) That the person receives services that remov… (this text has been trimmed due to space limits).	(i). One repositioning chart for a hospital level resident did not have monitoring completed as per care plan timeframes. (ii). A hospital level resident requiring regular repositioning did not have a repositioning chart in place as documented in the care plan interventions. (ii). Two of two restraint monitoring charts reviewed did not have monitoring completed as per care plan or policy timeframes.	(i). – (iii). Ensure monitoring records are completed as per care plan and policy requirements.	PA Low	In Progress
Health care and support workers shall have the opportunity to discuss and review performance at defined intervals.	Performance appraisals have not been completed for three staff who have been employed for more than 12 months.	Ensure that staff performance appraisals are completed annually as scheduled.	PA Low	In Progress
Governance bodies shall ensure compliance with legislative, contractual, and regulatory requirements with demonstrated commitment to international conventions ratified by the New Zealand government.	There was no documented evidence that measurable and specific annual facility goals have been developed or reviewed as required.	Ensure measurable facility measurable and specific goals are developed each year and regularly reviewed.	PA Moderate	In Progress

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: 20 February 2024

Audit type:Surveillance Audit

Audit date: 06 September 2022

Audit type:Certification Audit

Audit date: 18 March 2021

Audit type:Surveillance Audit

Audit date: 04 September 2019

Audit type:Certification Audit

Audit date: 03 December 2018

Audit type:Surveillance Audit

Audit date: 20 March 2018

Audit type:Surveillance Audit

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