Woodhaugh Resthome and Hospital
Profile & contact details
|Premises name||Woodhaugh Resthome and Hospital|
|Address||1027 George Street North Dunedin Dunedin 9016|
|Service types||Medical, Rest home care, Geriatric|
|Certification/licence name||Otago Care Limited - Woodhaugh Resthome and Hospital|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||17 October 2020|
|Certification period||24 months|
|Provider name||Otago Care Limited|
|Street address||403 Princes Street Dunedin Central Dunedin 9016|
|Post address||1027 George Street North Dunedin Dunedin 9016|
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: 14 August 2018
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.||(i) There was no signage on one toilet. (ii) One resident stated they felt cold in the North wing. (iii) One toilet had no lock in place. (iv) Paint was peeling on the floor of one shower. (v) One shower had a rusty handrail, and another had no handrails. (vi) No call bell cords for residents to reach when in bathrooms independently||(i)-(vi) Ensure all shower and toilet areas are compliant with current legislation.||PA Low||In Progress|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Two staff (one RN and one HCA) employed in January or February this year did not have completed orientation checklists on file. Following the draft report, the manager advised that this has been addressed.||Ensure that staff files evidence that all staff have fully completed the orientation programme.||PA Low||Reporting Complete||17/12/2018|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||Interviews with management and review of rosters identified the service has made improvements to staffing and increased staffing hours since last audit. Rosters sighted evidenced adequate cover to support current residents. However, concerns about turnover of new staff, and staffing levels including answering bells in a timely manner were identified in interviews with three caregivers, four of six residents and two relatives. During the audit a call bell was not answered in a timely fashion a… (this text has been trimmed due to space limits).||Ensure there call bell response time is monitored and answered in a timely manner Ensure staffing levels are continually reviewed and monitored with staff.||PA Low||Reporting Complete||17/12/2018|
|Information of a private or personal nature is maintained in a secure manner that is not publicly accessible or observable.||Two of three access levels checked, allowed access contrary to planned permissions: i) An RN access level allows access to all employee information including other RNs personal file information such as reference checks and recruitment details. ii) The HCA with ‘read only’ access according to role permissions, had access to edit and delete care plans.||Ensure all access levels are tested and confirmed as meeting the access permissions template.||PA Moderate||Reporting Complete||17/12/2018|
|The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.||Progress notes were not consistently documented for two of seven resident files reviewed||Ensure progress notes are documented at required intervals||PA Moderate||Reporting Complete||17/12/2018|
|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) Of all the medication charts on the electronic system (42 - one was paper based), seven were overdue for a three-monthly medication review. The clinical leader is working with the GP to ensure they complete this when they undertake the three-monthly resident reviews. ii) The medication cupboard included four expired antibiotics for injection. iii) Three of the 13 electronic medication chart signing sheets documented ‘dose supplied’ with no documentation to evidence that the medication… (this text has been trimmed due to space limits).||i) Ensure that the GP documents the three-monthly medication reviews on the medication charts. ii) Ensure that all medication is within date. iii) Ensure that all medication administered is taken.||PA Moderate||Reporting Complete||17/12/2018|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i) One rest home resident with significant behaviours that challenge over a period had no documented specialist review such a mental health for older people. (ii) One resident with a chronic wound did not have specialist review from the wound care nurse. (iii) Three wounds did not have a documented management plan.||(i)-(ii) Ensure that specialist input is sought for care as needed. (iii) Ensure that all wounds have a documented wound management plan.||PA Moderate||Reporting Complete||17/12/2018|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Two hospital level files did not identify all resident needs; (i) Resident one; did not include care and support for BIPAP, an indwelling catheter that regularly blocks or a preference for sleeping in a chair. (ii) Resident two had an up to date interRAI for a recent change of care level (rest home to hospital) but the long-term care plan had not been updated to reflect the care needs. Two rest home files did not identify all resident needs. (i) Resident one did not include falls interventio… (this text has been trimmed due to space limits).||Ensure care plans document interventions for all identified resident needs||PA Moderate||Reporting Complete||17/12/2018|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||There is no current provision or system in place for staff to access NZQA qualifications standards.||Implement a process to enable staff to access NZQA qualifications relevant to their employment.||PA Low||Reporting Complete||02/05/2019|
|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 of three admissions for 2018 did not have the initial interRAI assessment and long-term care plan documented within set timeframes||Ensure that admission timeframes are adhered to for interRAI and care planning||PA Moderate||Reporting Complete||02/05/2019|
|All buildings, plant, and equipment comply with legislation.||The renovation of the upstairs area is not complete, examples include: flooring for toilet and other areas, accessible ramps and heating.||Complete the renovation of the upstairs area; flooring for toilet and other areas, accessible ramps and ensure heating prior to admission of hospital residents (and rest home residents)||PA Low||Reporting Complete||04/10/2019|
|All buildings, plant, and equipment comply with legislation.||The renovation of the upstairs area is not complete, examples include flooring for toilet and other areas, accessible ramps and heating.||Complete the renovation of the upstairs area; flooring for toilet and other areas, accessible ramps and ensure heating prior to admission of hospital residents (and rest home residents).||PA Low||In Progress|
|The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.||One rest home resident did not have documentation regarding a fall occurring outside of the facility where the resident sustained a fracture.||Ensure progress notes are maintained following all incidents and changes in condition.||PA Moderate||In Progress|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||ii) There were no interventions on the care of a plaster cast for the rest home level resident on respite care. ii) Interventions lacked detail on personal cares/showering for a complex hospital level resident. iii) There was no signs or symptoms or management plan for a hospital level resident dependent in insulin. iv) There were no interventions on bowel cares and management of constipation for a hospital resident with complex needs. v) Interventions did not reflect recommendation by the… (this text has been trimmed due to space limits).||(i)-(vi) Ensure all interventions in long-term and short-term care plans are reflective of current needs of residents.||PA Moderate||In Progress|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i). The repositioning chart for one hospital resident with a pressure injury was not completed as required to provide evidence that the resident had been re-positioned as specified in the care plan. (ii) Two of the wounds had inadequate assessment or description and there were inadequate wound care plans in place for two of the wounds||(i) Ensure that re-positioning charts are completed and that residents are re-positioned at the frequency specified in their care plan. (ii) Ensure that wound assessments are adequate and wound care plans are in place for all residents with wounds.||PA Moderate||In Progress|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||i) Internal audits not completed according to schedule. No audits have been completed in July or August (to date of the audit) ii) There has been no environmental audit completed since the last audit.||i) Ensure internal audits are completed according to the schedule. ii) Ensure an environmental audit is completed.||PA Low||In Progress|
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: 14 August 2018
Audit type:Surveillance Audit
- Woodhaugh Resthome and Hospital - Aug 2018 (docx, 37.52 KB)
- Woodhaugh Resthome and Hospital - Aug 2018 (pdf, 147.72 KB)
Audit type:Certification Audit
- Woodhaugh Resthome and Hospital - Aug 2018 (docx, 53.75 KB)
- Woodhaugh Resthome and Hospital - Aug 2018 (pdf, 183.55 KB)
Audit type:Surveillance Audit
- Woodhaugh Resthome and Hospital - Feb 2018 (docx, 38.02 KB)
- Woodhaugh Resthome and Hospital - Feb 2018 (pdf, 149.02 KB)
Audit type:Provisional Audit