Premise details
- Address
- 4 Spence Lane Whakatane 3120
- Total beds
- 78
- Service types
- Rest home care, Geriatric, Medical
Certification/licence details
- Certification/licence name
- Bupa Care Services NZ Limited - Mary Shapley Rest Home & Hospital
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- Bupa Care Services NZ Limited
- Street address
- Level 2 109 Carlton Grove Road Newmarket Auckland 1023
- Postal address
- PO Box 113054 Newmarket Auckland 1149
- Website
- http://www.bupa.co.nz/
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 evaluate progress against quality outcomes. | (i). There is no documented evidence of 2023 health and safety goals progress being measured and evaluated as scheduled for the year. (ii). Where audits have been completed and there are corrective actions identified, there is no evidence of actions that have been put in place being followed up and signed off when completed. | (i). Ensure progress towards goals is measured and evaluated. (ii). Ensure corrective actions are followed up and signed off when completed | PA Low | Reporting Complete | |
| Fundamental to the development of a care or support plan shall be that: (a) Informed choice is an underpinning principle; (b) A suitably qualified, skilled, and experienced health care or support worker undertakes the development of the care or support plan; (c) Comprehensive assessment includes consideration of people’s lived experience; (d) Cultural needs, values, and beliefs are considered; (e) Cultural assessments are completed by culturally competent workers and are accessible in all settin | Two hospital and two rest home care plans have interventions that do not match the residents’ current assessed needs. | Ensure care plan interventions are current and meet residents assessed needs. | PA Low | Reporting Complete | |
| Service providers shall ensure there is a system to identify, plan, facilitate, and record ongoing learning and development for health care and support workers so that they can provide high-quality safe services. | The annual training programme since last audit has not been fully implemented. | Provide evidence that training is being conducted for all staff as per annual education and training plan. | PA Low | Reporting Complete | |
| Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services. | The service does not have sufficient numbers of registered nurses to have a registered nurse on duty at all times in the hospital level care as per ARRC agreement D17.4. | Ensure there is adequate coverage of all shifts by a registered nurse to meet the requirements of the ARRC contract D17.4. | PA Low | Reporting Complete | |
| Service providers shall evaluate progress against quality outcomes. | (i). There is no documented evidence of 2024 health and safety goals progress being measured and evaluated as scheduled for the year. (ii). Where audits have been completed and there are corrective actions identified, there is no evidence of actions that have been put in place being followed up and signed off when completed. | (i). Ensure progress towards goals is measured and evaluated. (ii). Ensure all corrective actions are documented, followed up and signed off when completed. | PA Moderate | In Progress | |
| Fundamental to the development of a care or support plan shall be that: (a) Informed choice is an underpinning principle; (b) A suitably qualified, skilled, and experienced health care or support worker undertakes the development of the care or support plan; (c) Comprehensive assessment includes consideration of people’s lived experience; (d) Cultural needs, values, and beliefs are considered; (e) Cultural assessments are completed by culturally competent workers and are accessible in all settin | (i). There were no signs and symptoms for hyper- and hypoglycaemia documented for one rest home resident with diabetes. (ii). There were no interventions or early warning signs documented for one hospital level resident with cellulitis. (iii). One care plan for a resident at hospital level of care with frequent falls did not have adequate detail for falls prevention. | (i). & (ii). Ensure care plans describe in detail the early warning signs to be reported to the registered nurse. (iii). Ensure care plans are sufficiently detailed to meet the needs of individual residents. | PA Moderate | In Progress | |
| In implementing care or support plans, service providers shall demonstrate: (a) Active involvement with the person receiving services and whānau; (b) That the provision of service is consistent with, and contributes to, meeting the person’s assessed needs, goals, and aspirations. Whānau require assessment for support needs as well. This supports whānau ora and pae ora, and builds resilience, self-management, and self-advocacy among the collective; (c) That the person receives services that remov | (i). One hospital level resident had four unwitnessed falls in one month; corresponding neurological observations were not completed in the frequency and timeframes required by the policy. (ii). One hospital level resident identified as a high falls risk had a care plan intervention described as intentional rounding three-hourly; however, this was not completed frequently enough to adequately monitor the resident. | (i). Ensure neurological observations are completed according to the policy. (ii). Ensure interventions (such as intentional rounding) are completed frequently enough to adequately monitor residents. | PA Moderate | In Progress | |
| Service providers shall ensure there is a system to identify, plan, facilitate, and record ongoing learning and development for health care and support workers so that they can provide high-quality safe services. | The annual training programme since last audit has not been fully implemented. | Provide evidence that training is being conducted for all staff as per annual education and training plan. | PA Moderate | In Progress | |
| Service providers ensure competent health care and support workers manage medication including: receiving, storage, administration, monitoring, safe disposal, or returning to pharmacy. | Review of staff files showed seven staff, including one registered nurse who works full time, were overdue for their annual medication competency tests. | Ensure medication competencies are completed on time. | PA Moderate | In Progress | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | Three of six staff files for those who have been employed for over one year, did not have an annual appraisal completed. | Ensure staff have the opportunity to discuss and review performance at defined intervals as per Bupa policy. | PA Low | In Progress | |
| My complaint shall be addressed and resolved in accordance with the Code of Health and Disability Services Consumers’ Rights. | Six of six complaints reviewed had no evidence of written acknowledgment, investigation or resolution to the satisfaction of the complainant. | Ensure all complaints are acknowledged, addressed, and resolved in accordance with the Code of Health and Disability Services Consumers’ Rights and Bupa policy. | PA Moderate | In Progress | |
| Single-use medical devices shall not be reused or remanufactured unless a formal risk assessment process has been followed and documented and approved by the governance body. | Policy and correct procedures for single use items (gloves) were observed not to be followed at the time of audit. | Ensure policy and procedure for the single use items are followed. | PA Low | In Progress | |
| I shall give informed consent in accordance with the Code of Health and Disability Services Consumers’ Rights and operating policies. | Two of six resident files reviewed did not have written acknowledgement of informed consent on file. | Ensure residents give informed consent in accordance with the Code of Health and Disability Services Consumers’ Rights, and this is recorded as per operating policies. | 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 corrective action manager.
- Date action reported complete
The date that the corrective action manager was told the issue was fixed.
Audit reports
About audit reports
Audit reports for this rest home’s latest audits can be downloaded below.
Before you begin
Before you download the audit reports, please read our guide to rest home certification and audits. The guide gives an overview of the auditing process and explains what the audit reports mean.
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.
Before 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) appear on the rest home’s page. As the rest home completes the required actions, the status on the website updates.
Audit date:
Audit type: Surveillance Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Surveillance Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Surveillance Audit
