Whitby Rest Home and Hospital
Profile & contact details
|Premises name||Whitby Rest Home and Hospital|
|Address||4 Observatory Close Whitby Porirua 5024|
|Service types||Dementia care, Rest home care, Psychogeriatric, Geriatric, Medical|
|Certification/licence name||Bupa Care Services NZ Limited - Whitby Rest Home & Hospital|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||16 November 2019|
|Certification period||36 months|
|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|
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: 03 December 2018
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|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 sighted at audit has not been reviewed since January 2016.||Ensure the hazard register is reviewed by the health and safety committee at timeframes as per policy.||PA Low||Reporting Complete||22/05/2019|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||(i)The dementia unit had unlabelled and dated food in the fridge and the cupboards (ii) Food in fridges was not all dated and labelled in the main kitchen fridges (iii) Cooked meats in the main kitchen fridge was not dated on opening (iv) The main kitchen floor was not clean||(i)-(iii) Ensure all food is appropriately dated and labelled (iv) Ensure the kitchen is maintained at a high level of cleanliness||PA Moderate||Reporting Complete||27/02/2019|
|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 residents admitted since the previous audit (one in dementia level care and one at rest home level care) did not have the initial interRAI and long-term care plans documented within set timeframes.||Ensure each stage of service provision is documented within set timeframes.||PA Moderate||Reporting Complete||27/02/2019|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||(i) Not all facility meetings have been completed according to the meeting schedule. There were two caregiver meetings, one health and safety and two quality meetings documented for 2018. Clinical/RN meetings do not occur weekly as scheduled. (ii) Where staff meetings have occurred, the minutes do not reflect discussion of quality data including infection control trends, incident data including falls, skin tears, medications incidents or pressure injuries. (iii) Adverse event data is colle… (this text has been trimmed due to space limits).||(i) Ensure that facility meetings take place according to the meeting schedule. (ii) Ensure staff meetings include discussion of quality data. (iii) Ensure that all incidents and accidents are analysed, and action plans documented as needed, as per Bupa policy. (iv) Ensure that the internal audit schedule is adhered to and that all required corrective action plans are completed and signed off. (i) Ensure survey results are discussed at staff meetings and areas identified for improvement a… (this text has been trimmed due to space limits).||PA Moderate||Reporting Complete||13/05/2019|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i)Care plans did not document all care plan interventions. (a) In the psychogeriatric unit, one resident did not have interventions to manage aggressive episodes and one resident did not have intervention for restraint in the long-term care plan. (b) In the dementia unit, one resident did not have interventions for managing smoking. (ii) One initial assessment for a resident in the psychogeriatric unit was not fully completed. (iii) One resident in the psychogeriatric unit was observed smokin… (this text has been trimmed due to space limits).||(i)Ensure that care plans document all care interventions. (ii) Ensure that assessments are fully completed. (iii) Ensure that residents are supervised in the psychogeriatric unit. (iv) Ensure that monitoring is undertaken according to the care plan. (v) Ensure that neurological observations are documented according to Bupa policies.||PA Moderate||Reporting Complete||13/05/2019|
|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)The medication room in the dementia unit is situated off the secure kitchen. All staff have access to the secure kitchen and the medication room is not able to be locked. (ii) The fridge temperatures in the hospital wing had not been monitored daily as per policy (iii) The hospital wing medication trolley contained eye drops which had not been dated on opening||(i)Ensure that the medication room in the dementia unit can be locked (ii) Ensure that fridge temperatures are recorded per Bupa policy (iii) Ensure that eye drops are dated on opening||PA Moderate||Reporting Complete||13/05/2019|
|The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.||The dementia unit had a strong malodour.||Ensure the dementia unit is odour free.||PA Low||Reporting Complete||13/05/2019|
|The facilitation of safe self-administration of medicines by consumers where appropriate.||One self-medicating resident in the hospital wing had not had their self-medication assessment reviewed since 2017.||Ensure that self-medicating residents have a three-monthly review of the self-medication assessment by the GP||PA Low||Reporting Complete||15/05/2019|
|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 residents with restraint (one hospital and one resident in the psychogeriatric unit) did not have three-monthly reviews of their restraint documented as per policy.||Ensure that resident restraints are evaluated as per policy||PA Low||Reporting Complete||22/05/2019|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||(i) There are 26 caregivers that work in the dementia and psychogeriatric care units, six have completed the required dementia standards and seven are in progress of completing. Thirteen caregivers are yet to complete their dementia standards, ten of these staff have been employed in the units for over eighteen months (ii) Attendance at compulsory training sessions is less than 20% (iii) Expired competencies are evident for (but not limited to): medication (four staff), controlled drug manag… (this text has been trimmed due to space limits).||(i) Ensure that all caregivers that work in the dementia and psychogeriatric care units have completed the required dementia standards (ii) Ensure all staff attend mandatory in-service training (iii) Ensure annual competencies are completed as required||PA Moderate||Reporting Complete||22/05/2019|
|The service respects the physical, visual, auditory, and personal privacy of the consumer and their belongings at all times.||Communal net pants were being used for hospital residents.||Ensure net pants are named and for individual use only.||PA Low||Reporting Complete||22/05/2019|
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: 03 December 2018
Audit type:Surveillance Audit
- Whitby Rest Home and Hospital - Dec 2018 (docx, 38.96 KB)
- Whitby Rest Home and Hospital - Dec 2018 (pdf, 156.08 KB)
Audit type:Surveillance Audit
- Whitby Rest Home and Hospital - Mar 2018 (docx, 37.15 KB)
- Whitby Rest Home and Hospital - Mar 2018 (pdf, 148.49 KB)
Audit type:Certification Audit
- Whitby Rest Home and Hospital - Sep 2016 (docx, 47.98 KB)
- Whitby Rest Home and Hospital - Sep 2016 (pdf, 187.86 KB)
Audit type:Partial Provisional Audit
- Whitby Rest Home and Hospital - May 2015 (docx, 44.86 KB)
- Whitby Rest Home and Hospital - May 2015 (pdf, 133.38 KB)
Audit type:Surveillance Audit
- Whitby Rest Home and Hospital - Sep 2014 (docx, 82.43 KB)
- Whitby Rest Home and Hospital - Sep 2014 (pdf, 502.37 KB)
Audit type:Certification Audit