The Willows Home and Hospital

Profile & contact details

Premises details
Premises nameThe Willows Home and Hospital
Address 16 Princes Street Otahuhu Auckland 1062
Total beds29
Service typesRest home care, Geriatric, Medical
Certification/licence details
Certification/licence nameThe Willows Home and Hospital Limited - The Willows Home and Hospital
Current auditorThe DAA Group Limited
End date of current certificate/licence20 April 2025
Certification period24 months
Provider details
Provider nameThe Willows Home and Hospital Limited
Street address16 Princes Street Otahuhu Auckland 1062
Post address16 Princes Street Otahuhu Auckland 1062

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: 21 February 2023

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Service providers shall evaluate progress against quality outcomes.Not all quality is evaluated for outcomes and not all corrective actions are signed off as closed. To ensure that all quality outcomes are evaluated, and corrective actions are implemented then signed of as closed. PA LowIn Progress
Meaningful activities shall be planned and facilitated to develop and enhance people’s strengths, skills, resources, and interests, and shall be responsive to their identity.There is no evidence of individualised activities programme. Service provider to ensure there is a system in place to develop and enhance resident's strengths, skills and interests which is responsive to their identity e.g., an activities calendar. PA LowIn Progress
Service providers shall identify and implement appropriate security arrangements relevant to the people using services and the setting, including appropriate identification.There is no evidence documenting that residents are aware and/or have been provided information about the CCTV cameras in the building. To provide evidence to ensure that all residents are aware of the CCTV cameras in the building. PA LowReporting Complete08/08/2023
Service providers ensure competent health care and support workers manage medication including: receiving, storage, administration, monitoring, safe disposal, or returning to pharmacy.I. Four doses of PRN medicines were administered in 72 hours and there was no documented evidence that the effectiveness was monitored. II. Ten of the 10 medication charts reviewed had no medication reconciliation completed in the last two months. I. All PRN medicine administered is to be monitored and documented for effectiveness. II. All medications received from the pharmacy are to have medication reconciliation completed and documented in the individual resident’s medication chart. PA ModerateReporting Complete08/08/2023
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 health care assistant hours to cover the current residents admitted and their high acuity of care required on an afternoon shift. To ensure that there is adequate health care assistant support/hours to meet the requirements for up to and including the current 26 residents. PA ModerateReporting Complete08/08/2023
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).There is a risk of cross infection to staff and residents in regard to current laundry practices. To ensure safe handling of dirty laundry. PA LowReporting Complete16/08/2023
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.Four out of the five files reviewed had interRAI assessments completed after 21 days of admission into the facility. Residents are to have their interRAI assessment completed within 21 days of admission. PA ModerateReporting Complete16/08/2023
My service provider shall ensure my services are operating in ways that are culturally safe.Residents that identify as Māori do not have their Māori cultural needs identified in their care plan. To ensure that all residents that identify as Māori have their Māori cultural needs identified in their care plan. PA LowReporting Complete30/10/2023
Planned review of a person’s care or support plan shall: (a) Be undertaken at defined intervals in collaboration with the person and whānau, together with wider service providers; (b) Include the use of a range of outcome measurements; (c) Record the degree of achievement against the person’s agreed goals and aspiration as well as whānau goals and aspirations; (d) Identify changes to the person’s care or support plan, which are agreed collaboratively through the ongoing re-assessment and review … (this text has been trimmed due to space limits).I. There was no evidence that changes were initiated in the care plan when residents progress was different from expected. II. Short term care plans were not completed for acute conditions. III. The residents' identified needs are not reflected in the care plans. IV. Six monthly care plan evaluations are overdue. V. Māori residents do not have a Māori health care plan. VI. InterRAI outcome measures are not used to support care plan goals and interventions. I. Where progress is different from expected changes to care plan needs to be initiated. II. All acute condition requires a short-term care plan. III. Residents care plan needs to reflect the resident's current needs as identified in the interRAI assessment. IV. All care plans are to be evaluated every six months. V. Cultural needs for Māori need to be specifically identified and documented in care plans. VI. InterRAI outcome measures are to be used to support care plan goals and interventions… (this text has been trimmed due to space limits).PA ModerateReporting Complete30/10/2023
There shall be clear processes for communicating the decisions for declining entry to a service.There is no clear process of managing and communicating the decisions for declining entry to service. To have a system which has a clear process for communicating the decisions for declining entry to a service. PA LowReporting Complete30/10/2023
Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care.The majority of meeting minutes for the last 12 months did not show evidence of detailed discussions and actions discussed. Resident meetings do not occur. No one was able to understand and/or interpret the handwritten analysis completed for monthly infections. To ensure that all meeting minutes reflect detailed discussions and actions discussed. To ensure that resident meetings occur. To ensure that handwritten documents are legible. PA LowReporting Complete30/10/2023

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.

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