Eileen Mary Retirement Complex

Profile & contact details

Premises details
Premises nameEileen Mary Retirement Complex
Address 44 Trafalgar St Dannevirke 4930
Total beds58
Service typesGeriatric, Rest home care
Certification/licence details
Certification/licence nameEileen Mary Age Care Limited
Current auditorThe DAA Group Limited
End date of current certificate/licence14 August 2018
Certification period48 months
Provider details
Provider nameEileen Mary Age Care Limited
Street address 44 Trafalgar Street Dannevirke 4930
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: 19 July 2016

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.At Eileen Mary there is not a formal process for monitoring and reporting against the implementation of corrective action plans. This has led to plans not being effectively implemented and / or issues continuing without resolution. For example: The Nursing care plan internal audits which have been completed in April and June 2016 have identified the same types of issues. Audits of the kitchen have also been completed several times in 2016 with issues identified but without formal corrective ac… (this text has been trimmed due to space limits).Develop or use an existing process of implementing and monitoring corrective action plans to ensure they are completed and issues do not recur. Link this process to management reporting to enable follow-up. PA ModerateReporting Complete24/11/2016
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.Aspects of assessment and review of care plans, medication and self-administration competencies for residents are not always provided within the required timeframes. Provide evidence all stages of service provision are completed in a timely manner. PA LowReporting Complete27/02/2017
The appointment of appropriate service providers to safely meet the needs of consumers.On the day of audit the facility had completed only 44% of their interRAI assessments for their current residents and by the end of the month would have completed 56% of interRAI assessments. A staff member has assigned responsibility for coordinating interRAI assessment but there are insufficient resources to achieve 100% of assessments with current allocations. Review the current resource allocations to achieve the interRAI assessment requirements of the facility’s contracts. PA LowReporting Complete27/02/2017
The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code.While complaints have been responded to, the responses have not been prepared with a continuous quality improvement focus which is the intent of the organisation’s policies and procedures for complaint management and responses. Complaint responses have not included additional information on alternative avenues for complaint resolution which complainants may wish to pursue (ie, the Health and Disability Commissioner), as outlined in the Code. Ensure that all complaint responses follow the organisation’s policies and information on additional avenues for complaint resolution are included in complaint resolution correspondence. PA LowReporting Complete27/02/2017
All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.Storage of dry goods, frozen foods and tinned items are not compliant with current guidelines. Provide evidence all aspects of food storage comply with current legislation and guidelines. PA LowReporting Complete27/02/2017

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.

Audit reports

Audit date: 19 July 2016

Audit type:Surveillance Audit

Audit date: 27 May 2014

Audit type:Certification Audit

Audit date: 20 November 2012

Audit type:Surveillance Audit

Audit date: 27 June 2011

Audit type:Certification Audit

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