Premise details
- Address
- 112 Riverside Road Orewa 0931
- Total beds
- 44
- Service types
- Rest home care
Certification/licence details
- Certification/licence name
- Maygrove Rest Home Limited - Maygrove Lifecare
- Current auditor
- The DAA Group Limited
- End date of current certificate/licence
- Certification period
- 24 months
Provider details
- Provider name
- Maygrove Rest Home Limited
- Street address
- Level 5 25 Broadway Newmarket Auckland 1023
- Postal address
- PO Box 56114 Dominion Road Auckland 1446
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 ensure competent health care and support workers manage medication including: receiving, storage, administration, monitoring, safe disposal, or returning to pharmacy. | Prescribed eye drops and inhalers were not dated when in use, and expired medicines are not stored appropriately to return to pharmacy. | All medications not in use requires storing properly or returned to the pharmacy. All opened eye drops, creams, and inhalers should have clearly marked opening and expiry dates. | PA Moderate | Reporting Complete | |
| My service provider shall embed and enact Te Tiriti o Waitangi within all its work, recognising Māori, and supporting Māori in their aspirations, whatever they are (that is, recognising mana motuhake). | There is no evidence that the organisation is supporting Māori residents in their cultural aspirations or recognizing their mana motuhake (self-determination and autonomy). | Cultural care plans will be developed for all Māori residents in collaboration with the residents and their whānau. These plans will guide staff in addressing the residents' cultural care needs. Additionally, staff will receive education on incorporating Te Whare Tapa Whā into care planning, ensuring a holistic approach that respects and integrates physical, mental, spiritual, and family health aspects. | PA Low | In Progress | |
| My service provider shall ensure my services are operating in ways that are culturally safe. | No culturally safe training has been provided for care staff to ensure culturally safe care is provided for residents who identify as Māori. | To ensure cultural training is provided to all staff to meet the needs of residents who identify as Māori. | PA Low | In Progress | |
| My service provider shall ensure cultural safety for Pacific peoples and that their worldviews, cultural, and spiritual beliefs are embraced. | Work has commenced to develop processes for Pacific peoples and their world views. Currently there are no policies or processes for staff to follow. | To ensure a cultural plan and model of care for Pasifika people is developed and implemented. | PA Low | In Progress | |
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | Results of internal audits are not consistent with audit findings, for example, resident care plans and activities progress records are not documented, or reviews updated, in records reviewed but audit results show that all information is documented. | To ensure the internal audits completed are consistent with the findings of each individual audit completed and that action is taken accordingly in a timely manner. | PA Low | In Progress | |
| My service providers shall provide opportunities for discussion and clarification about my rights. | Five residents interviewed reported that they had not been informed about their health and disability consumer rights. | Education and awareness on the Code for all residents within the facility. This includes providing comprehensive information and ensuring that all residents fully understand their rights and the services available to them under the Code. Regular training sessions, informative materials, and one-on-one discussions should be implemented to enhance resident knowledge and awareness. | PA Low | In Progress | |
| Care or support plans shall be developed within service providers’ model of care. | Five of the six audited care plans were not signed or dated by a registered nurse. | All care plans must be signed and dated by a registered nurse upon completion. | PA Low | In Progress | |
| My service provider shall facilitate support for me in accordance with my wishes, including independent advocacy. | There is a significant need for ongoing education and awareness to ensure staff residents and whanau are well-informed about the available advocacy support services. | Regular education sessions for staff, residents, and whānau are needed to increase awareness and understanding of the available advocacy support services. | PA Low | In Progress | |
| There shall be clear processes for communicating the decisions for declining entry to a service. | There is no clear process for communicating entry and decline for service. | A working document is required to provide evidence of both entry and decline decisions. Staff education is necessary to ensure they understand the importance of measuring these rates effectively. | PA Low | 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 | Cultural assessments were inadequately documented, resulting in a lack of support for personal choices. Care plans did not incorporate elements such as rākau rongoā, mirimiri, or karakia. | All Māori care plans are to be reviewed to incorporate residents' personal wishes, including culturally relevant goals, interventions, and evaluations. | PA Low | In Progress | |
| Service providers shall have a documented AMS programme that sets out to optimise antimicrobial use and minimising harm. This shall be: (a) Appropriate for the size, scope, and complexity of the service; (b) Approved by the governance body; (c) Developed using evidence-based antimicrobial prescribing guidance and expertise (which includes restrictions and approval processes where necessary and access to laboratory diagnostic testing reports). | There is no antimicrobial stewardship (AMS) programme that sets out to optimise antimicrobial use and minimising harm, that has been developed, implemented and approved by governance for this rest home. | To ensure an antimicrobial stewardship programme appropriate for the size and nature of this rest home be developed, implemented and approved by governance. | PA Low | In Progress | |
| Service providers demonstrate routine analysis to show entry and decline rates. This must include specific data for entry and decline rates for Māori. | Entry documentation did not evidence ethnicity data or demonstrate entry and decline rates for Māori. Administration and management did not understand the reporting requirements. | A working document is to be established to document the entry and decline rates of all residents, including ethnicity data for Māori residents. This data is to be reported during quality meetings to monitor entry and decline rates specifically for Māori residents. Staff education is required to ensure the importance of measuring these rates effectively is understood. | PA Low | In Progress | |
| Service providers shall have a clearly defined and documented IP programme that shall be: (a) Developed by those with IP expertise; (b) Approved by the governance body; (c) Linked to the quality improvement programme; and (d) Reviewed and reported on annually. | There was no evidence of an annual infection prevention review, nor was there an active antimicrobial stewardship program authorized by the governing body. | An AMS program must be implemented and approved by the governing body, with the IPC and AMS programs subject to an annual review. | PA Low | 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 | There is no evidence of involvement from family or residents in the care planning process. | All care plans must be completed in collaboration with residents and whānau to ensure personalised and culturally safe care. | PA Low | In Progress | |
| 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 | There is no evidence of family or resident input into care planning, nor any evidence of updates to care plans in response to changes in health needs. | All care plans require updating to incorporate resident and whānau input, as well as any changes in health needs. | PA Low | In Progress | |
| Service providers, shall evaluate the effectiveness of their AMS programme by: (a) Monitoring the quality and quantity of antimicrobial prescribing, dispensing, and administration and occurrence of adverse effects; (b) Identifying areas for improvement and evaluating the progress of AMS activities. | The AMS programme is not monitored for prescribing, dispensing and administration, and there is no evidence of AMS surveillance (refer to 5.4). | An AMS program requires approval from the governing body, with effective AMS surveillance practices implemented at regular intervals to ensure the safe use of antibiotics in elderly patients. | PA Low | In Progress | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | The annual staff appraisals are not currently up to date. Six of seven staff annual performance appraisals had not been completed in the staff records reviewed. | To ensure each staff member has an annual performance review completed in a timely manner, and that the review is recorded in the individual staff record. | PA Low | In Progress | |
| Surveillance methods, tools, documentation, analysis, and assignment of responsibilities shall be described and documented using standardised surveillance definitions. Surveillance includes ethnicity data. | The RN used standardised definitions for the surveillance of infections monitored in the documentation reviewed, However, no resident ethnicity data was collated and recorded accurately as required when the surveillance was undertaken. | To ensure at the time of surveillance of resident’s infections, that the resident’s ethnicity is recorded. | PA Low | In Progress | |
| Service providers shall understand Māori constructs of oranga and implement a process to support Māori and whānau to identify their own pae ora outcomes in their care or support plan. The support required to achieve these shall be clearly documented, communicated, and understood. | Residents interviewed identified as Māori felt there was a lack of understanding of Māori and whānau support systems to enable Māori residents to identify their own pae ora outcomes and to have these documented in their individual care plan. | To ensure that staff receive further education to be able to support Māori residents and their whanau to identify their own pae ora outcomes and to have these included in the care planning process. | PA Low | In Progress | |
| Results of surveillance and recommendations to improve performance where necessary shall be identified, documented, and reported back to the governance body and shared with relevant people in a timely manner. | There is no evidence of infection prevention surveillance data being completed over the past three months. | All infections and surveillance outcomes must be documented and reported to the governing body as required | PA Low | In Progress | |
| I shall give informed consent in accordance with the Code of Health and Disability Services Consumers’ Rights and operating policies. | Consent forms for care, including advance directives, are not undergoing the required biannual or annual reviews. | All resident consent forms and advance directives require thorough reviews and updates in accordance with organisational policies and guidelines. Additionally, all advance directives must be reviewed by a GP in consultation with the resident and their family/whānau. | PA Low | In Progress | |
| Infection prevention education shall be provided to health care and support workers and people receiving services by a person with expertise in IP. The education shall be: (a) Included in health care and support worker orientation, with updates at defined intervals; (b) Relevant to the service being provided. | There was no evidence of infection prevention and AMS education for staff, residents, or whānau. | Service providers shall provide educational resources that are available in te reo Māori and are accessible and understandable for Māori accessing services. | PA Low | In Progress |
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
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: Certification Audit
Audit date:
Audit type: Provisional Audit
