Masonic Court Rest Home

Profile & contact details

Premises details
Premises nameMasonic Court Rest Home
Address 1 Masonic Drive Wanganui East Wanganui 4500
Total beds53
Service typesRest home care
Certification/licence details
Certification/licence nameRuapehu Masonic Association Trust
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence22 May 2018
Certification period36 months
Provider details
Provider nameRuapehu Masonic Association Trust
Street address 1 Masonic Drive Wanganui East Wanganui 4500
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: 30 March 2015

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.Three out of five internal audits completed for this year do not have corrective actions/recommendations signed off Ensure corrective actions are signed off when completed. PA LowReporting Complete25/09/2015
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Staff have not attended Code of Rights, open disclosure and complaints management within the last two years. Staff have not attended annual infection control education Ensure all staff attend compulsory education requirements. PA LowReporting Complete25/09/2015
The organisation has a clearly defined and documented infection control programme that is reviewed at least annually.There has been no annual review of the infection control programme. Ensure the infection control programme is reviewed annually. PA LowReporting Complete25/09/2015
An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.Four out of five complaints did not evidence follow-up and resolution to the satisfaction of the complainant. The complaints register is not up-to-date. Ensure documentation reflects complaints are followed-up and resolved to the satisfaction of the complainant. Maintain a current complaints register. PA LowReporting Complete25/09/2015
The appointment of appropriate service providers to safely meet the needs of consumers.Performance appraisals had not been completed annually in five of seven staff files sampled. Ensure performance appraisals are completed annually. PA LowReporting Complete11/01/2016
Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.Each medication prescribed was not dated on five of ten medication charts. Ensure each medication is dated on the medication chart. PA LowReporting Complete11/04/2017
Consumers have a right to full and frank information and open disclosure from service providers.Fourteen incident forms were reviewed for November 2016. Five out of fourteen incident forms reviewed did not evidence notification to family. Ensure that all incident forms include notification to family/EPOA. PA LowReporting Complete11/04/2017
The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk.(i)Two out of fourteen incident forms reviewed did not have RN follow up/assessment and sign off. (ii)An identified pressure injury had not been reported through the accident/incident system. (i)Ensure that all incident forms identify RN assessment (if required) and sign off. (ii) Ensure an incident form is completed for a pressure injury. PA LowReporting Complete11/04/2017
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.(i)There was no wound assessment in place for one resident with a pressure injury (link tracer 1.3.3). The pressure injury risk assessment had not been reviewed and interventions documented did not reflect the residents pressure injury risk status; (ii) One resident identified as high risk of falls did not have appropriate falls prevention interventions documented. The same resident did not have interventions documented to manage weight loss; (iii) The mobility status had not been updated for … (this text has been trimmed due to space limits).(i)Ensure wound assessments are completed; (ii) – (iv) Ensure interventions are documented to reflect the resident’s current health status and the supports required to meet the resident needs. PA ModerateReporting Complete11/04/2017

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: 30 March 2015

Audit type:Certification Audit

Audit date: 16 January 2014

Audit type:Surveillance Audit

Audit date: 20 March 2012

Audit type:Certification Audit

Audit date: 28 June 2011

Audit type:Surveillance Audit

Audit date: 16 March 2010

Audit type:Certification Audit

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