Gladys Mary Rest Home

Profile & contact details

Premises details
Premises nameGladys Mary Rest Home
Address 7 Glamorgan Avenue Tamatea Napier 4112
Total beds38
Service typesDementia care, Rest home care
Certification/licence details
Certification/licence nameBupa Care Services NZ Limited - Gladys Mary Rest Home
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence30 March 2020
Certification period36 months
Provider details
Provider nameBupa Care Services NZ Limited
Street addressLevel 2 109 Carlton Grove Road Newmarket Auckland 1023
Post addressPO Box 113054 Newmarket Auckland 1149

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: 25 October 2018

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines.(i) Three of fourteen medication charts reviewed (two dementia and one rest home) did not document the indication for use of prescribed ‘as required’ medication; and (ii) Two medication signing charts (dementia) did not evidence that medication (nutritional supplement) had been given as prescribed. (i) Ensure indications for use of ‘as needed’ medications are documented on medication charts, to include any extra guidance to ensure safe administration. (ii) Ensure medications are administered as prescribed. PA ModerateReporting Complete21/08/2017
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.A total of twenty caregivers are employed to work in the dementia unit. One caregiver has not completed the dementia standards and has worked in the unit for longer than 12 months. Ensure all caregivers working in the dementia unit have completed the required standards as per the ARC contract. PA LowReporting Complete21/08/2017
Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome.Care plan evaluations were not documented to reflect resident’s current status or in meeting goals. Document a care plan evaluation to determine the effectiveness of care interventions prior to replacement/continuation of long-term care plan. PA LowIn Progress
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.(i)Two of eleven staff working in the secure dementia unit had been in their roles for over three years but had not attained dementia unit standards. The previous finding relating to dementia education has not been addressed. (ii) Training around de-escalation and managing behaviours that challenge, end of life care and pressure injury prevention and management has not been completed in the last two years. (i)All care staff working in the secure dementia unit are to hold/attain dementia units within 18 months of commencing work in the unit. (ii) Ensure all mandatory training is completed. PA ModerateIn Progress
The facilitation of safe self-administration of medicines by consumers where appropriate.The policy covering self-administration stated a competency assessment is to be undertaken three monthly. There was no evidence that after the initial competency check that a full competency is being undertaken three monthly for the one resident who was self-medicating. Ensure a three-monthly competency is completed for the resident self-medicating PA LowIn Progress
Consumers have a right to full and frank information and open disclosure from service providers.Two of ten incident forms reviewed identified that next of kin (NOK) had not been notified. There was no documented record of why they were not notified. Ensure documentation reflects that NOK have been notified of incidents/accidents unless requested otherwise. PA LowIn 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

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 reports

Audit date: 25 October 2018

Audit type:Surveillance Audit

Audit date: 31 January 2017

Audit type:Certification Audit

Audit date: 14 July 2015

Audit type:Surveillance Audit

Audit date: 13 January 2014

Audit type:Certification Audit

Audit date: 22 March 2013

Audit type:Surveillance Audit

Audit date: 24 April 2012

Audit type:Verification Audit

Audit date: 31 January 2012

Audit type:Certification Audit

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