A rest home overwhelmed by a coronavirus outbreak that claimed 12 lives was found in breach of its obligations including cleanliness, food and laundry services - and authorities became frustrated after a lack of contact by the owner.
Documents obtained by the Herald detail how Canterbury DHB took over Rosewood Rest Home after concerns about its ability to cope with what became New Zealand's deadliest Covid-19 cluster. They show:
• A lack of available staff meant the facility breached its contract obligations in multiple areas including cleaning, food and laundry services and emergency provision of supplies.
• An apparent lack of contact from Rosewood's owner exasperated health authorities, and the DHB wasn't able to confirm if there was an emergency health plan in place as required.
However, the NZ Aged Care Association says a Ministry of Health review of all rest home clusters, due this week, should also examine whether DHBs did enough to help - and the appropriateness of moving vulnerable, frail residents to hospitals, where many died.
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The first case at Rosewood was confirmed on April 3. The cluster had its first death on April 9 - a woman aged in her 90s and the country's second Covid-19 fatality. Eleven more Rosewood residents would die.
Canterbury DHB told the Herald the only reason for appointing a temporary manager was to help out at a time when Rosewood's own manager and many staff were in self-isolation.
However, a letter to the facility on April 9 - four days after the DHB stepped in and the day of the first death - reveals frustration.
"I am concerned that we had not heard from you or your general manager following confirmation of the outbreak ... that resulted in the DHB needing to transfer 20 of the residents to Burwood Hospital, and your staff going into self-isolation leaving no staff to care for the remaining 44 residents," wrote Carolyn Gullery, the DHB's executive director of planning, funding and decision support.
"This is a challenging time for everyone, however, our expectation is that you, as the owner, would have urgently contacted your CDHB contract manager as this exceptional situation developed so we could work together to manage this.
"We have been unable to confirm whether you have a Major Incident and Health Emergency Plan as required by Section D19.6 of the Aged-Related Residential Care Agreement (ARRC)."
This situation had "resulted in an urgent and serious level of risk to your residents' clinical wellbeing and safety" and required the DHB to step in on April 5, including the transfer of the dementia residents to Burwood.
According to the letter, other steps taken by the DHB included urgently establishing rosters and providing staff, including for clinical, kitchen and cleaning; providing meals for residents and "for staff who have been unable to take a break"; and managing laundry off-site. There were also maintenance issues including a leaking water cylinder that flooded the laundry.
"We consider that, under Clause A22.1, you have failed to meet the requirements of the ARRC Agreement," Gullery wrote, adding that breaches covered food services, cleaning and laundry, human resources and providing sufficient staff, and "emergency provision of personal supplies".
"In our opinion, this required urgent action to protect the health and safety of your residents, and as a result we appointed a temporary manager on 6 April."
The documents were released under the Official Information Act, along with a covering letter in which Gullery said the DHB had no concerns about Rosewood prior to the outbreak.
"The only reason for appointing a temporary manager was because of the need for leadership during the time that Rosewood staff, including the facility manager, were either off sick or had been stood down by public health because of the possibility of becoming unwell."
That required the appointment of the temporary manager until Rosewood's manager could come out of isolation, which happened on April 22.
Mike Kyne, a spokesman for Rosewood owners Malcolm and Lynda Tucker, said the statements in the covering letter "set out the correct facts", but a more detailed response wasn't possible by deadline.
Canterbury DHB has previously told the Herald the challenges of dealing with a worsening outbreak with too few staff led to shortcomings at Rosewood, with the DHB confirming "a number of issues regarding safe practice, including the way PPE [personal protective equipment] was used".
Six rest homes have had Covid-19 cases, and some successfully ended transmission quickly. Two others - Rosewood and CHT St Margaret's residential aged-care home in Auckland's Te Atatu - account for 16 of New Zealand's 22 Covid-linked deaths.
Director general of health Dr Ashley Bloomfield noted the differing results when announcing a review into "what has worked well, and what could be improved".
Simon Wallace, chief executive of the Aged Care Association, which represents most aged-care facilities including Rosewood, said that review should be released in the coming days.
"I think it's really important that we wait to see what is in that review. My understanding of that is it will be looking at the role of all the parties involved in all of those clusters - that's the rest homes, the public health units, and the district health boards."
Deaths linked to both Rosewood and St Margaret's happened after DHBs moved residents to hospitals, because of staffing pressures at the facilities. The appropriateness of that would be examined by the ministry's review, Wallace suggested.
"The review will be interesting, because always the priority in any situation like this - and this is what the clinicians will tell you - is to try and keep elderly, vulnerable people in their own homes, wherever possible. That is the best place for them to be - in their own homes, and the rest home is their home.
"Canterbury DHB made that decision because of staffing, and that's understandable. But if you look at the other clusters [without fatalities] those people stayed in the rest home. It is never desirable to move quite frail, elderly people."
Wallace was on a Zoom call with DHB staff and Tucker on April 8, which was followed by the April 9 letter from Gullery.
He didn't have the details of the situation, but expected the stated breaches were because Rosewood's staff had been stood down, and so services couldn't be provided.
"The industry is not beyond reproach, nor is any rest home beyond reproach. And there may well have been deficiencies, if you like, and that was probably because there were no staff - they were transitioning from having all the staff stood down."
Documents obtained by the Herald have also revealed concerns about PPE use at St Margaret's rest home, including a lack of bins for safe disposal.
There was a shortage of other equipment, and all residents were only swabbed 11 days after a staffer tested positive - turning up undetected cases, two of whom later died.
Wallace has said those dangerous testing gaps were despite the efforts of rest homes and his association to have more residents swabbed. The Ministry of Health had "held on to their case definition and would not test".