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 2022|
|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: 27 August 2020
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|The methods, frequency, and materials used for cleaning and laundry processes are monitored for effectiveness.||Unpleasant odours were noted in the south wing during the audit.||Ensure unpleasant odours are managed.||PA Low||Reporting Cancelled|
|Consumers who have additional or modified nutritional requirements or special diets have these needs met.||There was noted negative feedback in the resident meetings, but outcomes or corrective actions were not documented therefore it was difficult to determine whether these issues were addressed. Three rest home and two hospital residents were overall not satisfied with the meal services. One rest home resident and one hospital resident stated the meals were cold at times. Two rest home residents and two staff reported on occasions they run out of food at teatime and toast is provided in the plac… (this text has been trimmed due to space limits).||Ensure resident concerns around the meals are addressed and clearly documented. Ensure any incidents of meal shortage is documented through the quality and corrective actions established.||PA Low||Reporting Cancelled|
|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.||(i) Three of the seven files (two hospital and one rest home) did not have initial facility-based assessments, interRAI assessments, long-term care plans, and evaluations, completed within the required timeframes. (ii) Two of the hospital files did not have a current activities assessment and evaluation.||(i)-(ii). Ensure all assessments, care planning and evaluation timeframes meet expected timeframes in line with policy.||PA Low||Reporting Cancelled|
|The responsibility for infection control is clearly defined and there are clear lines of accountability for infection control matters in the organisation leading to the governing body and/or senior management.||(i) The IC coordinator was unclear who the IC team is. (ii) The policy describes a combined H&S/IC meeting. A review of the meeting minutes for 2020 did not identify a discussion of IC stats or analysis. Infections identified are not separated into areas or rest home/hospital. (iii) There is no identified analysis/trends or benchmarking.||(i) Ensure the role of the IC team/committee is clear. (ii) Ensure infection control stats are discussed at the meeting. (iii) Ensure stats are analysed, trends identified, and corrective actions established where possible and addressed through meetings.||PA Low||Reporting Cancelled|
|The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.||There was no call bell installed in the living areas of the Gables (upstairs) wing.||Ensure call bells are installed in the living areas of the Gables wing before residents are residing in this area.||PA Low||Reporting Cancelled|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||There was a lack of wound documentation to reflect current good practice. (i) There were no wound assessments completed to evidence progression or deterioration of the wound bed. (ii) There were no wound management plans utilised to guide staff around dressings, or frequency of changes. (iii) There was no corresponding evidence of wound progression or deterioration. (iv) There are inadequate wound dressing supplies sighted in the treatment room.||(i)-(iii) Utilise an assessment, management and evaluation process with all wounds. (iv) Ensure there is adequate and appropriate supplies of wound dressings.||PA Moderate||Reporting Cancelled|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||(i) There was no documented evidence of analysis and trending of quality data. (ii) Staff and residents interviewed stated that the outcomes of implemented corrective actions were not routinely reported to meetings.||(i). Ensure analysis and trending of quality data is documented. (ii). Ensure implemented corrective actions are reviewed for effectiveness and the outcome reported to meetings.||PA Low||Reporting Cancelled|
|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 service does not currently monitor the medication room temperature. (ii) The registered nurse was observed not keeping the medication trolley within their line of sight.||(i) Implement monitoring of the treatment room to ensure the temperature does not exceed more than 25 degrees. (ii) Ensure the medication trolley is kept locked when out of sight.||PA Moderate||Reporting Cancelled|
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: 27 August 2020
Audit type:Certification AuditAudit 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