Marinoto Rest Home
Profile & contact details
| Premises name | Marinoto Rest Home |
|---|---|
| Address | 72 Matai Street Inglewood 4330 |
| Total beds | 32 |
| Service types | Medical, Rest home care, Geriatric |
| Certification/licence name | Inglewood Welfare Society Incorporated - Marinoto Rest Home |
|---|---|
| Current auditor | Health and Disability Auditing New Zealand Limited |
| End date of current certificate/licence | 01 July 2024 |
| Certification period | 36 months |
| Provider name | Inglewood Welfare Society Incorporated |
|---|---|
| Street address | 72 Matai Street Inglewood 4330 |
| Post address | 72 Matai Street Inglewood 4330 |
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: 07 March 2023
| Outcome required | Found at audit | Action required | Risk rating | Action status | Date action reported complete |
|---|---|---|---|---|---|
| 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) Five electronic medication charts did not have an allergy status documented and (ii) not all eye drops in use had been dated on opening. | (i) Ensure allergies are documented on the medication charts and (ii) ensure all eye drops are dated on opening. | PA Moderate | Reporting Complete | 26/11/2021 |
| Key components of service delivery shall be explicitly linked to the quality management system. | (i) Not all internal audits have been completed according to the schedule. (ii) Not all meetings document that quality information is shared and discussed, examples include lack of incident and accident data and analysis, health and safety and internal audit information for the December, February and March staff meetings. Infection control was not documented for the December and March meetings. The quality meeting did not document discussion of incidents, health and safety and internal audit.… (this text has been trimmed due to space limits). | (i) Ensure that internal audits are completed according to the schedule. (ii) Ensure that meetings reflect information and discussion of the quality outcomes. | PA Low | Reporting Complete | 26/11/2021 |
| A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented. | Action plans have not been documented for all internal audits, where an issue was identified. Examples include: audits for August, September and October. | Ensure an action plan is documented and followed up where a shortfall is identified. | PA Moderate | Reporting Complete | 26/11/2021 |
| A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers. | Not all training has been provided over the last two years including health and safety, Treaty of Waitangi (or cultural care), informed consent and clinical assessment/care of a deteriorating resident (which the GP had suggested they should undertake). | Ensure all training is provided as per the schedule. | PA Low | Reporting Complete | 26/11/2021 |
| The organisation has a clearly defined and documented infection control programme that is reviewed at least annually. | The infection control programme has not been reviewed within the last year. | Ensure the infection control programme is reviewed annually. | PA Low | Reporting Complete | 26/11/2021 |
| The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes. | (i) Two of six unwitnessed falls did not have neurological observations completed as per protocol, (ii) There was no pain assessment or monitoring of pain for one respite care resident with identified pain on admission and requiring ‘as required’ analgesia and, (iii) There was no monitoring in place as per accident/incident corrective action plan for a resident who had wandered. | (i) Ensure neurological observations are completed as per protocol and (ii)-(iii) ensure monitoring requirements are implemented to meet the resident’s needs. | PA Moderate | Reporting Complete | 26/11/2021 |
| Service delivery plans demonstrate service integration. | There is no documented evidence of resident/relative input into care planning and evaluation of care. | Ensure there is documented resident/relative involvement in long-term care plans and evaluations. | PA Low | Reporting Complete | 25/02/2022 |
| Service providers shall follow the National Adverse Event Reporting Policy for internal and external reporting (where required) to reduce preventable harm by supporting systems learnings. | (i)There were no recorded investigations on the adverse event form to prevent future risks related to three of five unwitnessed falls. (ii)The adverse event forms are not always signed off in a timely manner by the clinical manager or facility manager. | Ensure each reported adverse event evidence a completed investigation, and (ii) ensure each reported adverse event is reviewed and signed off in a timely manner by the clinical manager/facility manager. | PA Moderate | Reporting Complete | 19/09/2023 |
| Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services. | There is not sufficient RN coverage on the roster to meet the requirements of the ARRC D17.4.a. i. | Ensure there is sufficient coverage of RN shifts to meet the requirements of the ARRC D17.4.a. i. | PA Moderate | Reporting Complete | 19/09/2023 |
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.
From 1 June 2009 to 28 February 2022 rest homes were audited against the Health and Disability Services Standards NZS 8134:2008. These standards have been updated, and from 28 February 2022 rest homes are audited against Ngā Paerewa Health and Disability Services Standard NZS 8134:2021.
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 Ngā Paerewa Health and Disability Services Standard.
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: 07 March 2023Audit type:Surveillance Audit
Audit date: 27 April 2021Audit type:Certification Audit
Audit date: 24 October 2019Audit type:Surveillance Audit
Audit date: 23 August 2019Audit type:Partial Provisional Audit
Audit date: 19 November 2018Audit type:Partial Provisional Audit
Audit date: 23 April 2018Audit type:Certification Audit
Audit date: 02 June 2017Audit type:Surveillance Audit