Maryann Rest Home and Hospital

Profile & contact details

Premises details
Premises nameMaryann Rest Home and Hospital
Address 59 Brecon Road Stratford 4332
Total beds49
Service typesGeriatric, Medical, Dementia care, Rest home care
Certification/licence details
Certification/licence nameAge Care Central Limited - Maryann Rest Home and Hospital
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence15 May 2020
Certification period36 months
Provider details
Provider nameAge Care Central Limited
Street address 59 Brecon Road Stratford 4332
Post addressPO Box 318 Stratford 4352

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: 21 February 2017

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.One caregiver has worked in the dementia unit for over one year and has not completed an NZQA approved dementia course Ensure all caregivers complete an NZQA approved course on dementia care within their first year of employment in the dementia unit as per ARC contract. PA LowReporting Complete29/05/2017
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.The internal audit programme was not completed as per the internal audit schedule for 2016 (10 of 19 audits were sighted as completed for 2016). Interviews with the managers confirmed that internal audits were behind schedule in 2016. Also missing was the timely communication of quality results to staff. Ensure internal audits are completed as per the internal audit schedule. Ensure that staff receive timely information relating to internal audit results, trends in data and corrective actions. PA LowReporting Complete01/06/2017
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.There was a lack of evidence to verify that a sample of corrective actions were implemented. Ensure there is documented evidence to confirm that corrective actions are implemented. PA LowReporting Complete01/06/2017
Advance directives that are made available to service providers are acted on where valid.Four of seven files sampled (two from the dementia unit and two from the hospital) contained an advance directive that was not valid. One advance directive was signed by an EPOA where the resident was not deemed competent to sign. Three forms had been signed by the GP that the resident was not competent to make an advance directive, and documented as not for resuscitation, but there was no indication that this was a clinically indicated decision. The template was addressed on the day. … (this text has been trimmed due to space limits).Ensure that all advance directives are valid. PA LowReporting Complete20/06/2017
In assessing whether restraint will be used, appropriate factors are taken into consideration by a suitably skilled service provider. This shall include but is not limited to: (a) Any risks related to the use of restraint; (b) Any underlying causes for the relevant behaviour or condition if known; (c) Existing advance directives the consumer may have made; (d) Whether the consumer has been restrained in the past and, if so, an evaluation of these episodes; (e) Any history of trauma or abuse, whi… (this text has been trimmed due to space limits).The assessment process failed to identify the risks associated with restraint use and therefore did not link identified risks to the residents’ care plans Ensure the restraint assessment process identifies risks associated with the use of restraint and interventions to manage these risks are identified in the care plan. PA LowReporting Complete20/06/2017
Each episode of restraint is evaluated in collaboration with the consumer and shall consider: (a) Future options to avoid the use of restraint; (b) Whether the consumer's service delivery plan (or crisis plan) was followed; (c) Any review or modification required to the consumer's service delivery plan (or crisis plan); (d) Whether the desired outcome was achieved; (e) Whether the restraint was the least restrictive option to achieve the desired outcome; (f) The duration of the restraint episode… (this text has been trimmed due to space limits).The restraint evaluation process was evidenced only by the GP’s signature. Ensure the evaluation of restraint includes addressing all aspects of the criterion. PA LowReporting Complete20/06/2017
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.(i) Two care plans for residents with identified behaviours did not have interventions to manage the behaviours clearly documented. (ii) Three of nine wounds had periods of three to four days where wound reviews had not been documented in the electronic database. (i) Ensure interventions to manage behaviours that challenge are documented in the electronic database. (ii) Ensure that all wound reviews are documented and saved. PA LowReporting Complete20/06/2017

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: 21 February 2017

Audit type:Certification Audit

Audit date: 19 August 2015

Audit type:Surveillance Audit

Audit date: 17 March 2014

Audit type:Certification Audit

Audit date: 20 June 2013

Audit type:Surveillance Audit

Audit date: 28 May 2013

Audit type:Verification Audit

Audit date: 16 November 2012

Audit type:Verification Audit

Audit date: 24 February 2012

Audit type:Certification Audit

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