Whitby Rest Home and Hospital

Profile & contact details

Premises details
Premises nameWhitby Rest Home and Hospital
Address 4 Observatory Close Whitby Porirua 5024
Total beds103
Service typesDementia care, Rest home care, Psychogeriatric, Geriatric, Medical
Certification/licence details
Certification/licence nameBupa Care Services NZ Limited - Whitby Rest Home & Hospital
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence16 November 2019
Certification period36 months
Provider details
Provider nameBupa Care Services NZ Limited
Street addressLevel 2 109 Carlton Grove Road Newmarket Auckland 1023
Post addressPO 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: 06 September 2016

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Each episode of restraint is documented in sufficient detail to provide an accurate account of the indication for use, intervention, duration, its outcome, and shall include but is not limited to: (a) Details of the reasons for initiating the restraint, including the desired outcome; (b) Details of alternative interventions (including de-escalation techniques where applicable) that were attempted or considered prior to the use of restraint; (c) Details of any advocacy/support offered, provided o… (this text has been trimmed due to space limits).One restraint file in the psychogeriatric unit did not have the bedrail restraint included in the care plan. One restraint in the hospital had the restraint included in the care plan, but not the risks associated with its use. The enabler file reviewed in the hospital included the enabler on the care plan, but not the risks associated with its use. One hospital resident was not monitored according to timeframes and one hospital enabler was not monitored through progress notes as directed by B… (this text has been trimmed due to space limits).Ensure that care plans document the restraint or enabler in use and the risks associated with their use. Ensure monitoring is documented as directed. PA LowReporting Complete16/01/2017
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.(i) In the dementia unit there were two unlabelled containers of chemicals on the cleaner’s trolley. (ii) Three oxygen cylinders were not secured in the storage area. Ensure chemicals are stored safely. PA LowReporting Complete16/01/2017
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.(i) There were two staff meetings and two quality meetings documented for 2016. Clinical focused meetings have not always occurred monthly. (ii) Quality information is not documented as discussed, at the meetings (eg, such as audits outcomes, complaints, infection control and incidents and accidents). (iii) There is no documentation to evidence that trends are reported, analysed and action plans implemented as needed. (iv) There was no documented evidence that action plans have been utilised … (this text has been trimmed due to space limits).(i) Ensure that meetings take place according to the meeting schedule. (ii) Ensure that quality data and outcomes are reported and discussed at meetings. (iii) - (iv) Ensure that trends analysis is undertaken, reported and followed-up. PA LowReporting Complete16/02/2017
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.Registered nurse follow-up following resident related incidents was not always documented to ensure resident safety and ongoing care and monitoring. This included neurological observations not being undertaken for an appropriate length of time following a blow to the head or unwitnessed fall for two dementia residents, three hospital residents, and two psychogeriatric residents. For these residents neurological observations were undertaken for an average of twice only. Incident forms were fo… (this text has been trimmed due to space limits).Ensure that post incident monitoring such as neurological observation are documented according to Bupa timeframes. Ensure that RNs document a follow-up review of residents post injury. PA ModerateReporting Complete16/02/2017
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.One resident who was charted regular pain relief did not have it documented as administered. On interview, the RN stated the family had requested it not to be given. The GP had not been contacted or altered the medication order. Regular medication was not documented as administered to a resident twice in one day with no reason recorded as to why it was not given. Ensure medication administration is documented in line with legislation, protocols, and guidelines. PA LowReporting Complete16/02/2017
All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.There was no evidence that temperatures of three servery fridges containing resident food were monitored or recorded. Ensure all food is stored at the correct temperature and documentation reflects this. PA LowReporting Complete16/02/2017

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. 

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 reports

Audit date: 06 September 2016

Audit type:Certification Audit

Audit date: 01 May 2015

Audit type:Partial Provisional Audit

Audit date: 29 September 2014

Audit type:Surveillance Audit

Audit date: 13 September 2012

Audit type:Certification Audit

Audit date: 07 June 2011

Audit type:Surveillance Audit

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