Premise details
- Address
- 44 Trafalgar Street Dannevirke 4930
- Website
- https://www.promisia.co.nz/our-communities/eileen-mary-centre
- Total beds
- 58
- Service types
- Medical, Rest home care, Geriatric
Certification/licence details
- Certification/licence name
- Masonic Care Limited - Eileen Mary Care
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 12 months
Provider details
- Provider name
- Masonic Care Limited
- Street address
- 63 Wai-Iti Crescent Woburn Lower Hutt 5010
- Postal address
Progress on issues from the last audit
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.
| Outcome required | Found at audit | Action required | Risk rating | Action status | Date action reported complete |
|---|---|---|---|---|---|
| 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. | Not all adverse events that occur are documented in the incident and accident reporting system. | Ensure all events related to an incident/accident have a completed event form. | PA Low | Reporting Complete | |
| Service providers shall maintain an information management system that: (a) Ensures the captured data is collected and stored through a centralised system to reduce multiple copies or versions, inconsistencies, and duplication; (b) Makes the information manageable; (c) Ensures the information is accessible for all those who need it; (d) Complies with relevant legislation; (e) Integrates an individual’s health and support records. | The handover notes had care interventions documented that should be documented and integrated into the individual`s care plan. | Ensure supplementary information is integrated into the resident`s individual care record. | PA Low | Reporting Complete | |
| Alternative essential energy and utility sources shall be available, in the event of the main supplies failing. | There is no generator on site and an agreement to supply one in the event of mains power failure was not sighted. | Ensure a signed agreement with a generator supply company is held on site. | PA Low | Reporting Complete | |
| The frequency and extent of monitoring of people during restraint shall be determined by a registered health professional and implemented according to this determination. | Review of monitoring records show incomplete documentation of restraint monitoring charts. | Ensure restraint monitoring is documented as per the policy and care plan. | PA Low | Reporting Complete | |
| Planned review of a person’s care or support plan shall: (a) Be undertaken at defined intervals in collaboration with the person and whānau, together with wider service providers; (b) Include the use of a range of outcome measurements; (c) Record the degree of achievement against the person’s agreed goals and aspiration as well as whānau goals and aspirations; (d) Identify changes to the person’s care or support plan, which are agreed collaboratively through the ongoing re-assessment and review | (i). There is no NP/GP contract in place; therefore, the service is not meeting the ARRC contract clause D16.5 e (i). (ii). There were no interventions documented to guide staff around the management of two residents with a urinary tract infection, and resolution of the infection was also not documented. | (i). Ensure a NP/GP contract is in place to meet the ARRC contract. (ii). Ensure there are interventions documented to guide staff around all infections and resolution is documented. | PA Low | Reporting Complete |
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.
