Premise details
- Address
- 2 McKenzie Street Geraldine 7930
- Total beds
- 82
- Service types
- Dementia care, Rest home care, Geriatric, Medical
Certification/licence details
- Certification/licence name
- McKenzie Healthcare Limited - McKenzie HealthCare
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- McKenzie Healthcare Limited
- Street address
- 2 McKenzie Street Geraldine 7930
- 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 |
|---|---|---|---|---|---|
| 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. | The door from the lounge/dining room in the dementia unit leading to the outdoors were locked. | Ensure the door in the lounge/dining room leading to the outdoors stays unlocked to optimise independence. | PA Low | Reporting Complete | |
| Service providers shall evaluate progress against quality outcomes. | i). Management, quality improvement, full staff, RN/clinical and health and safety/infection control meetings have not been evidenced as being held as per the schedule. ii). Not all proposed actions and outcomes have been assigned, followed up or completed as required. | i). Ensure that management, quality improvement, full staff, RN/clinical, and health and safety/infection control meetings are completed as per the schedule. ii). Ensure proposed actions and outcomes are assigned, followed up and evidenced as completed as required. | PA Low | Reporting Complete | |
| Service providers shall engage with people receiving services to assess and develop their individual care or support plan in a timely manner. Whānau shall be involved when the person receiving services requests this. | (i). In three hospital level resident files, the initial interRAI assessment, six-month interRAI reassessments and initial care plans were not completed within the required timeframes. (ii). Three of seven resident files reviewed did not have long-term care plans documented within 21 days of admission. (iii). Two of five permanent residents did not have six-month interRAI reassessments completed. (iv). InterRAI assessments did not inform the care plan for five hospital level residents where the | (i). Ensure all initial and six-month interRAI reassessments and initial care plans were completed within the required timeframes. (ii). Ensure all resident files reviewed had long-term care plans documented within 21 days of admission. (iii). Ensure six-month interRAI assessments have been completed for all residents. (iv). Ensure all interRAI assessments inform the care plan for all where the interRAI was completed after the development of the care plan. (v). Ensure care plan evaluations and | 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). There were no current interventions documented for one hospital level resident around hygiene and pressure injury prevention management following a deterioration in condition. (ii). One hospital resident with pain and skin care requirements had these identified in the initial assessments; however, these were not documented in the long-term care plan. (iii). One resident’s care plan in the hospital area did not document a) identified triggers or personalised instructions; and b) interventi | (i)-(iv) Ensure that care plan interventions support residents assessed and current needs. (v). Ensure the review of activities care plans are completed as per the policy requirements/timeframes. | PA Moderate | Reporting Complete | |
| A medication management system shall be implemented appropriate to the scope of the service. | Out of the sixteen medication charts reviewed, eight did not have effectiveness of PRN medications administered recorded. | Ensure efficacy of the PRN medications administered is documented as per policy. | PA Low | Reporting Complete | |
| 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 policy requirements are not being completed for monitoring the quality and quantity of antimicrobial prescribing, dispensing, and administration and occurrence of adverse effects; identifying areas for improvement and evaluating the progress of AMS activities. | Ensure there are processes in place to monitor the quality and quantity of antimicrobial prescribing, dispensing, administration, and occurrence of adverse effects, identifying areas for improvement and evaluating the progress of AMS activities. | 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). There was limited evidence of the implementation of an audit schedule for April 2024-April 2025. (ii). Although most meetings were scheduled as completed; the content of the meetings did not always reflect that’s staff are informed of every aspect of performance of the quality programme (restraint, antimicrobial stewardship (AMS), internal audit results and related corrective actions). (iii). The directors report did not evidence feedback on AMS and restraint. | (i). Ensure that the internal audit schedule is implemented as scheduled. (ii). Ensure that meeting minutes evidence that staff are informed of all aspects related to the performance of the quality programme. (iii). Ensure the directors are informed of all aspects of the performance of the quality programme. | PA Low | Reporting Complete | |
| Service providers shall engage with people receiving services to assess and develop their individual care or support plan in a timely manner. Whānau shall be involved when the person receiving services requests this. | (i). The first long term care plans of two recent admissions (one rest home and one dementia levels of care) were developed after twenty-four days of the required timeframe. (ii). A long-term care plan of a hospital level resident was out of date by sixteen days. (iii). A long-term care plan of a resident in the dementia unit has been started, however, not all sections of the care plan have been completed. | (i). – (iii). Ensure care plans are developed and reviewed within the required timeframes | PA Moderate | Reporting Complete | |
| A medication management system shall be implemented appropriate to the scope of the service. | (i). Incidental sample was done by reviewing a completion report. Incidental sample evidenced that eleven medication charts are not reviewed by the GP every three months. (ii). Seven out of fifteen medication charts reviewed indicate administration of prn medications; however, effectiveness was not consistently documented in the medication electronic system or in the resident progress notes. | (i). Ensure the GP completes three monthly reviews of medication charts. (ii). Ensure that effectiveness / outcomes of administered prn medications are documented. | 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 | There were no twenty-four-hour diversional plans developed for three resident files reviewed in the dementia unit (sample extended by one). | Ensure twenty-four-hour diversional therapy plan is developed for residents in the dementia unit. | PA Moderate | 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. | (i). Seven HCAs who have completed their dementia unit standards had no evidence of any achievement of the unit standards on file to meet the ARRC contract clause E 4.5(f). (ii). Two of the HCAs have been enrolled for more than 18 months. | (i). Ensure HCAs working in the dementia have evidence of their achievement of the dementia unit standards on record to meet the requirements of the ARRC contract. (ii). Ensure that the healthcare assistants are enrolled to complete the relevant unit standards within 18 months of them starting to work in the dementia unit. | 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: Partial Provisional Audit
Audit date:
Audit type: Partial Provisional Audit
Audit date:
Audit type: Surveillance Audit
