Edale Aged Care
Profile & contact details
|Premises name||Edale Aged Care|
|Address||30 Bond Street Marton 4710|
|Service types||Dementia care, Geriatric, Rest home care|
|Certification/licence name||Masonic Care Limited - Edale Aged Care|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||22 May 2022|
|Certification period||36 months|
|Provider name||Masonic Care Limited|
|Street address||63 Wai-Iti Crescent Woburn Lower Hutt 5010|
Progress on issues from the last audit
What’s on this page?
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.
Details of corrective actions
Date of last audit: 05 March 2019
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||The service has not implemented hospital level of care and therefore do not have 24/7 RN cover.||Ensure staffing including 24/7 RN cover is in place prior to the occupancy of hospital level residents||PA Low||In Progress|
|All buildings, plant, and equipment comply with legislation.||(i)There is no documented preventative maintenance plan for ongoing maintenance and (ii) There are porous work surfaces in the kitchen resulting from chipped paintwork. Partial provisional: The kitchenette area in the proposed dementia unit poses a hazard to residents with exposure to a boiling jug and microwave.||(i)-(ii)Formulate and document a preventative maintenance plan and to attend to ongoing maintenance required such as the chipped paint surfaces in the kitchen. Partial provisional: Ensure the identified hazards in the kitchenette area are managed prior to occupancy.||PA Low||Reporting Complete||09/05/2019|
|Consumers are given the choice and advised of their options to access other health and disability services where indicated or requested. A record of this process is maintained.||A referral had not been sent for reassessment for one resident with hospital level needs including two-person sling hoist transfer, full feed and cares. The referral was sent at time of audit.||Ensure residents level of care is reassessed should their needs indicate.||PA Low||Reporting Complete||17/06/2019|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||Education for medication management and infection control has not been completed annually. Other two-yearly mandatory education has not been completed within the last two years including, for example, nutrition, pain management, continence management and the ageing process.||Ensure all education and training requirements are offered and completed within the required timeframes.||PA Low||Reporting Complete||17/06/2019|
|The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.||A facility acquired sacral pressure injury that developed eight months ago had deteriorated to a grade 4 pressure injury. There was no evidence of an incident form completed or notification of family when the injury was first noted. There was no section 31 completed when the pressure injury deteriorated to a stage three. Documentation was completed on the day of audit.||Ensure incident forms are completed for pressure injuries and family are informed.||PA Moderate||Reporting Complete||17/06/2019|
|Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.||(i) There was no evidence available to confirm the menu had been reviewed by a registered dietitian. (ii) There was no evidence available to confirm one cook and a kitchenhand, who had both been in the positions for over ten months, had undertaken food safety training. One of the three was still orientating to the role.||(i)Ensure the menu is reviewed by a registered dietitian two yearly, and (ii) Ensure staff undertake food safety training in a timely manner.||PA Low||Reporting Complete||17/06/2019|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||(i) Corrective actions have been identified for audits with results less than 100%. Fourteen of 25 audits reviewed did not have the corrective actions signed off as completed. (ii) There is no evidence of audit outcomes discussed or documented in monthly reports or meeting minutes.||(i) Ensure corrective actions are signed off when completed. (ii) Ensure audit outcomes are discussed with staff and documented in meeting minutes.||PA Low||Reporting Complete||17/06/2019|
The outcome required by the Health and Disability Services Standards.
Found at audit
The issue that was found when the rest home was audited.
The action necessary to fix the issue, as decided by the auditor.
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.
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.
Before you begin
Before you download the audit reports, please read our guide to rest home certification and audits which gives an overview of the auditing process and explains what the audit reports mean.
What’s on this page?
Audit reports for this rest home’s latest audits can be downloaded below.
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.
Prior to 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 Health and Disability Services Standards.
Note: From November 2013, as rest homes are audited, any issues from their latest audit (the corrective actions required by the auditor) will appear on the rest home’s page. As the rest home completes the required actions, the status on the web site will update.
Audit reportsAudit date: 05 March 2019
Audit type:Partial Provisional Audit; Certification Audit
Audit type:Provisional Audit