Atawhai Mercy Assisi Home & Hospital

Profile & contact details

Premises details
Premises nameAtawhai Mercy Assisi Home & Hospital
Address 158 Matangi Road RD 4 Hamilton 3284
Total beds86
Service typesGeriatric, Medical, Rest home care
Certification/licence details
Certification/licence nameMercy Assisi Home & Hospital Hamilton Limited - Atawhai Mercy Assisi Home & Hospital
Current auditorThe DAA Group Limited
End date of current certificate/licence02 May 2019
Certification period36 months
Provider details
Provider nameMercy Assisi Home & Hospital Hamilton Limited
Street address 158 Matangi Road Hamilton 3284
Post address

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: 16 March 2016

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
There is a document control system to manage the policies and procedures. This system shall ensure documents are approved, up to date, available to service providers and managed to preclude the use of obsolete documents.The document control system is defined in policy however lacks guidance in the management of document review and archiving of documents. Presently documents which are reviewed are electronically overwritten to create a new version and the previous version is not retained in the system. Ensure the document control policy provides sufficient guidance for control and management of all documents and for archiving of obsolete documents. PA LowReporting Complete02/11/2016
A process to measure achievement against the quality and risk management plan is implemented.The audit programme (Action Albert) has no defined acceptable performance levels and when deficiencies have been identified; there is no evidence of more frequent monitoring or improvement activity. Not all data is available. Ensure the internal processes for audits are documented and audits include the required levels of performance for the area being audited. Less than optimal results are followed up to ensure the remedial plan has been effective. PA LowReporting Complete02/11/2016
Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include: (a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk; (b) A process that addresses/treats the risks associated with service provision is developed and im… (this text has been trimmed due to space limits).Although organisational risks are captured, there is a lack of integration between quality improvement, risk management and strategic planning. Risks are not consistently reviewed at a frequency relevant to the significance of the risk or any changes that have occurred. Develop integrated systems and processes which addresses the range of organisational risks to ensure that these are adequately monitored, analysed, evaluated and reviewed according to the nature and severity of the risk PA LowReporting Complete02/11/2016
Service providers follow a documented process for the safe and appropriate storage and disposal of waste, infectious or hazardous substances that complies with current legislation and territorial authority requirements.Chemicals are not adequately assessed for their hazardous properties therefore disposal of hazardous substances could potentially be inadequate. Review the onsite hazardous substances and create an accurate hazardous substances register which incorporates all aspects of hazardous substances management. PA LowReporting Complete02/11/2016

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. 

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.

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