Premise details
- Address
- 1 Masonic Drive Wanganui East Wanganui 4500
- Total beds
- 56
- Service types
- Medical, Geriatric, Rest home care
Certification/licence details
- Certification/licence name
- Ruapehu Masonic Association Trust - Masonic Court Rest Home
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 24 months
Provider details
- Provider name
- Ruapehu Masonic Association Trust
- Street address
- 1 Masonic Drive Wanganui East Wanganui 4500
- 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 |
|---|---|---|---|---|---|
| Meaningful activities shall be planned and facilitated to develop and enhance people’s strengths, skills, resources, and interests, and shall be responsive to their identity. | (i). Activity plans do not address and document resident aspirations and goals and activities to support these goals. (ii). The activity coordinator and the RNs were unclear regarding who would be writing activity plans and as a result, activity plans were not comprehensive holistic and resident centred. | (i). Ensure activity plans address and document resident individual aspirations, goals, and activities to support these goals. (ii). Ensure that roles and responsibilities are clearly defined for documenting individual activity plans. | PA Low | Reporting Complete | |
| A medication management system shall be implemented appropriate to the scope of the service. | On the day of audit, an electronic medication system failure meant that the lunch time medication round was undertaken over two hours late. The service had no back up system to ensure that medications could be given according to the prescription as part of a business continuity plan and staff were not aware of what to do. | Ensure there is a business continuity plan that documents a process for administering medications in the event of a system failure. | PA Moderate | Reporting Complete | |
| Buildings, plant, and equipment shall be fit for purpose, and comply with legislation relevant to the health and disability service being provided. The environment is inclusive of peoples’ cultures and supports cultural practices. | Testing and tagging for three vacuum cleaners, one microwave, the laundry iron and washing machines were not up to date. | Ensure all electrical equipment has evidence of a current test and tag. | PA Low | Reporting Complete | |
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | (i). Meetings have not been held as scheduled. (ii). Corrective actions from meetings have not consistently been documented, carried forward when identified or provide evidence of follow-up and sign off when completed. (iii)When there is an identified issue e.g. a high incidence of urinary tract infections, residents falls or a spike in choking episodes, there is no documented risk-based approach or critical review to improve service delivery. | (i)Ensure meeting are held as scheduled. (ii)Ensure loop closure with corrective actions identified. (iii)Ensure critical review of identified issues to improve service delivery. | PA Low | Reporting Complete | |
| Governance bodies shall ensure service providers’ structure, purpose, values, scope, direction, performance, and goals are clearly identified, monitored, reviewed, and evaluated at defined intervals. | (i). There was no evidence of regular reviews of the business plan through 2024. (ii). There was no evidence goals were met and signed off. | (i).& (ii). Ensure that business plan goals are monitored ongoing, evaluation of progress undertaken and signed off when completed. | PA Low | Reporting Complete | |
| My complaint shall be addressed and resolved in accordance with the Code of Health and Disability Services Consumers’ Rights. | (i). One complaint did not evidence acknowledgement, investigation, follow-up letters and resolution. (ii).Two complaints from 2024 (March 2024 and October 2024) have not been closed off. | (i)-(ii). Ensure that complaints shall be managed and resolved a per policy and HDC requirements. | 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. | There is no evidence to demonstrate that the service has a contingency planned in case of system failures related to resident records and medicine management. | Ensure there is a contingency plan in case of system failure. | PA Moderate | Reporting Complete | |
| Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided. | There is no evidence of completed orientation for three of the eight staff files reviewed. | Ensure that there is evidence of completed orientation in all staff files. | PA Low | Reporting Complete | |
| Service providers shall develop and implement policies and procedures in accordance with good employment practice and meet the requirements of legislation. | Four of eight staff files reviewed did not have reference checks completed. | Ensure that reference checks are completed as part of the employment process. | PA Low | Reporting Complete | |
| Service providers demonstrate routine analysis to show entry and decline rates. This must include specific data for entry and decline rates for Māori. | The service does not log ethnicity and does not undertake analysis of entry and decline rates for Māori. | Ensure routine analysis to show entry and decline rates. This must include specific data for entry and decline rates for Māori. | PA Low | Reporting Complete | |
| 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 | Neurological observations were not completed according to policy for three of four falls where neurological observations were required including one resident with a GCS score of six. | Ensure that neurological observations are completed according to policy where neurological observations are required. | PA Moderate | 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 | (i). One hospital level resident’s file for a Pasifika resident did not evidence interventions for a). Cultural interventions; b). interventions for the resident’s rehabilitation plan, or c). links to wound care plan. (ii). The risks and interventions for falls and risk of urinary tract infections were not documented for one hospital level resident. (iii). There were no interventions documented for a hospital level resident with poor eyesight. (iv). There were no interventions documented for ma | (i).- (iii). Ensure that care plans include care and support interventions for all identified needs. | PA Moderate | 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 | Two hospital and two rest home care plan evaluations did not evidence the degree of achievement against the resident’s goals and aspirations. | Ensure there are detailed evaluations documented. | PA Low | Reporting Complete | |
| Service providers shall identify external and internal risks and opportunities, including potential inequities, and develop a plan to respond to them. | (i)There is no evidence of resident satisfaction survey being completed as scheduled since last audit. (ii)There is no evidence to demonstrate that staff satisfaction survey was completed as scheduled since last audit | (i).&(ii). Ensure that satisfaction surveys are completed as scheduled and results are evidenced as being utilised to improve service delivery. | PA Low | Reporting 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. | (i). There is no incident report completed for a stage 3 pressure injury. (ii). One stage 3 pressure injury did not have SAC report completed as required. (iii). An event related to an altercation between two residents only has one incident form completed for the resident (with the behaviour of concern) and not the other resident who was hit. | (i).&(iii). Ensure incident/accident forms are completed as per policy. (ii). Ensure essential notifications to Health Quality and Safety Commission (HQSC) are completed as required. | 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: Certification Audit
Audit date:
Audit type: Surveillance Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Partial Provisional Audit
