Health commissioner finds pattern of demeaning care at Whakatāne rest home
Her complaint included that staff didn't accommodate her mother's hearing and speech problems, ignored her requests for help, failed to recognise she had a urinary tract infection and were slow to react when she had a fall.
Aged Care Commissioner Carolyn Cooper said in the report she found Golden Pond failed to provide services in a manner that treated the woman with respect, a breach of the Code of Health and Disability Services Consumers' Rights.
Cooper, however, acknowledged the home and hospital had changed many of its practices since the investigation.
The report detailed Golden Pond's apology letter, which said it was sorry for the way the woman was treated and the lack of communication and accountability.
The woman was in her 70s and received hospital-level care since her admission in May 2019.
She had a history of depression and limited vision and had been diagnosed with progressive supranuclear palsy, a complex, chronic neurological condition that affects speech, swallowing, eye movements and mobility.
Cameras were installed for security purposes and for the woman's daughter to check if her mother had any falls.
The woman's daughter became concerned about the care her mother was receiving based on events captured in 23 videos that were supplied to the commission as evidence.
She was frequently asking to use the toilet and staff became frustrated. They failed to recognise she had a urinary tract infection.
On the morning of her fall, she was left on the ground for 40 minutes before being found.
Golden Pond acknowledged there needed to be accountability for the failings in its care, but emphasised in its response to the commission that five years had passed and none of the staff members involved worked at Golden Pond anymore.
Cooper's report said three of the videos were particularly concerning, including one where a carer was arguing with the woman while she was on the toilet.
'In my view, this incident demonstrates an appalling disregard for [the woman's] dignity.'
In another video, the woman pleaded with staff to use the toilet but was told she should have gone earlier and that her incontinence pad would be sufficient.
'In my opinion, these repeated instances of demeaning conduct by several staff members, particularly in circumstances involving [the woman's] toileting when she was entirely reliant on staff for her cares, amount to a failure to provide services in a manner that respected [her] dignity.'
Cooper's report concluded there was evidence of a 'concerning pattern of demeaning and disrespectful treatment' involving six staff members, including two nurses.
'While there is individual accountability for these actions, in my view, the continued widespread and repeated actions by staff at Golden Pond reflect a culture of disrespect and disregard for the dignity of those under Golden Pond's care, for which, ultimately, I hold Golden Pond responsible.'
Cooper said Golden Pond had been aware of the woman's daughter's concerns since at least January 2020, and some action was taken.
'However, I consider that the continued inappropriate conduct of staff, over a period of months, indicates a failure by Golden Pond to manage, improve and monitor the situation adequately.'
She noted Golden Pond acknowledged in its response that it was too slow to pick up on the stress staff were under and put in strategies to deal with the woman's behaviour.
A 2025 Golden Pond audit was complimentary of the service, and Cooper said in the report she commended Golden Pond on the 'significant improvements' it had made since the complaint.
However, she still made the recommendation that Golden Pond provide evidence of its most recent staff training and education on elder abuse, respectful communication and conduct, and managing stress and challenging resident behaviours.
It had to provide evidence of that training to the commissioner within six months.
Kelly Makiha is a senior journalist who has reported for the Rotorua Daily Post for more than 25 years, covering mainly police, court, human interest and social issues.
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File photo. Photo: 123RF Multiple staff at a Whakatāne care home were demeaning and disrespectful to a resident in her seventies suffering a neurological condition in their care, the Aged Care Commissioner has found. Commissioner Carolyn Cooper's report into Golden Pond Private Hospital found staff repeatedly failed to treat the woman with dignity and respect, including ignoring and at times berating her pleas to go to the toilet, and standing over and arguing with her while she was on the toilet. The woman - called Mrs A - was in her seventies and lived at Golden Pond between May 2019 and November 2020, where she received hospital-level care for a neurological condition called progressive supranuclear palsy, affecting her speech, swallowing, eye movements and mobility. She was deaf, needing face-to-face conversations, and had a history of depression. Her daughter had installed security cameras in her mother's unit to watch over her belongings and to establish the cause of her falls, but became concerned with the way staff were treating her mother after reviewing the footage. She lodged complaints over a number of matters with the Health and Disability Commissioner. Cooper recommended that Golden Pond provide evidence of newly implemented staff training, including on elder abuse, in six months. Cooper watched 23 videos of interactions between staff members and Mrs A at Golden Pond, and found a "concerning pattern of demeaning and disrespectful treatment" involving six staff members, including two nurses. While noting that each video only captured a short period of time, Cooper said the way staff spoke to Mrs A in a repeatedly negative way showed a culture of disrespect for those under Golden Pond's care. Three videos between January and April 2020, relating to Mrs A toileting needs, were "particularly concerning". A video from January 2020 showed a nurse arguing loudly with Mrs A while she was sitting on the toilet, while Mrs A sounded distressed. Cooper said a healthcare assistant, who was in Mrs A's bedroom, stated she was wasting staff time. Cooper said the incident showed an "appalling disregard for Mrs A's dignity". "While it is not clear what happened prior to the clip shown in the video, there is no conceivable circumstance in which it would be acceptable for a carer to stand over a vulnerable consumer and argue with them while they are on the toilet." Another video, taken in April 2020, showed Mrs A sitting on a commode with a healthcare assistant standing next to her searching for toilet paper. Cooper said the video showed Mrs A saying she could not go to the toilet while the healthcare assistant was there, and the assistant responding abruptly that other residents could. A third video, from April 2020, showed Mrs A distressed and pleading to go to the toilet, but being told by healthcare assistants that her incontinence pad would suffice, and that she should have gone to the toilet earlier. Cooper said the independent clinical adviser, registered nurse Julia Russell, called the incident a "severe departure from the accepted standard of care". She said that concerns about Mrs A's care were raised as early as January 2020, but staff did not improve their conduct, and the situation was not adequately monitored for months. While staff would have been under stress due to the Covid-19 pandemic during these months, it was not an excuse for the behaviour, Cooper said. Cooper was also critical of Golden Pond's lack of records about Mrs A's care plan from the first half of 2020, and the fact that Golden Pond did not provide these records to the Health and Disability Commissioner after the investigation was launched. Cooper said that Golden Pond had made significant changes since a provisional decision relating to the investigation was released. Staff received education and training including about elder abuse, respectful conduct, managing stress and challenging resident behaviours. A new facility manager was appointed in 2021, and multiple policies, including one highlighting a zero tolerance towards abuse, were updated. Cooper said a March 2025 audit of Golden Pond found that residents were safe from abuse, and there were no examples of discrimination, coercion or harassment. Cooper recommended that Golden Pond provide evidence of the new training material and staff attendance records to the Health and Disability Commissioner in six months. Sign up for Ngā Pitopito Kōrero , a daily newsletter curated by our editors and delivered straight to your inbox every weekday.
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