Marinoto Rest Home
Profile & contact details
|Premises name||Marinoto Rest Home|
|Address||72 Matai Street Inglewood 4330|
|Service types||Rest home care|
|Certification/licence name||Inglewood Welfare Society Incorporated - Marinoto Rest Home|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||01 July 2018|
|Certification period||24 months|
|Provider name||Inglewood Welfare Society Incorporated|
|Street address||72 Matai Street Inglewood 4330|
|Post address||72 Matai Street Inglewood 4330|
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: 02 June 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|The needs, outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning.||(i)Two of two residents with regular reports of pain documented in the progress notes, had no evidence of pain assessments being completed. (ii)The wound assessments completed for the resident with a pressure injury (tracer) did not document the stage of the pressure injury.||(i)Ensure that pain assessments are completed for residents reporting pain. (ii) Ensure that all wound assessments are fully documented. (iii) Ensure all respite residents have a care plan for the time they are in care.||PA Low||Reporting Complete||10/10/2016|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||(1)One respite resident with multiple co-morbidities had no assessments or care plan documented 15 days after admission and no care plan documented following a change in health condition. (2) The following shortfalls were identified in care plans reviewed; i) The management of hypo or hyperglycaemia for two residents with Type II diabetes was not documented. ii) The management and monitoring required for a resident with a gastric ulcer and a recent history of gastro intestinal bleeding and a re… (this text has been trimmed due to space limits).||(1)Ensure that all residents have a documented care plan to cover their identified care needs. (2) Ensure that interventions are documented for all assessed care needs.||PA Moderate||Reporting Complete||05/08/2016|
|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 ten medication charts sampled had no documented evidence of a review of the medication by the GP. (ii) Six monthly pharmacy medication checks were completed but not signed by two people. (iii) Two of ten medication records reviewed did not have dates recorded for the weekly medication checks completed on-site. (iv) One Type II diabetic resident was charted glucagon for diabetic emergencies; however there was no glucagon on-site.||(i)Ensure that resident’s medication is reviewed by the GP at least every three months. (ii)Ensure that pharmacy medication checks are completed and signed by two people. (iii) Ensure that weekly medication checks are dated. (iv)Ensure that residents have medication charted for diabetic emergencies available on-site.||PA Moderate||Reporting Complete||05/08/2016|
|The facilitation of safe self-administration of medicines by consumers where appropriate.||One resident self-administering medication had not completed the required self-medication competency assessment since September 2015.||Ensure that residents who are self-administering medication have completed the required competencies.||PA Low||Reporting Complete||05/08/2016|
|Service providers responsible for medicine management are competent to perform the function for each stage they manage.||Five of five healthcare assistants administering subcutaneous insulin have not completed the required insulin administration competency.||Ensure staff administering medication has completed the required medication competencies.||PA Moderate||Reporting Complete||05/08/2016|
|Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.||(i)For one resident admitted for respite care, the staff were using prescriptions as the instruction to administer medication. The prescriptions did not have the route and/or dose times documented for nine of ten medications. (ii)The respite resident was admitted on an antibiotic that was not prescribed and there was no evidence that it was being administered and the resident was being administered lactulose and Hepa-merz sachets that were not prescribed. (iii)One resident was being administe… (this text has been trimmed due to space limits).||Ensure that all medication administered is prescribed according to the requirements of the Medicines Care Guides for Residential Aged Care and all contractual and legal requirements.||PA High||Reporting Complete||31/08/2016|
|Entry criteria, assessment, and entry screening processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies.||The amendments made in 2015 to clause D13.3 of the ARRC contract, regarding refund timeframes are not included in the admission agreement currently in use by the service.||Ensure that the current admission agreement aligns fully to the ARRC contract.||PA Low||Reporting Complete||10/10/2016|
|Consumers have a right to full and frank information and open disclosure from service providers.||Seven of fifteen accident/incident forms reviewed did not evidence notification to next of kin following an accident/incident||Ensure that next of kin are notified on any accidents/incidents||PA Low||Reporting Complete||10/10/2016|
|All records are legible and the name and designation of the service provider is identifiable.||Two of five care plans reviewed included updates around interventions. These updates were not dated and signed by the writer.||Ensure all clinical records and amendments to care plans are signed and dated by the writer.||PA Low||Reporting Complete||10/10/2016|
|Infection control education is provided by a suitably qualified person who maintains their knowledge of current practice.||The infection control coordinator has not completed any specific training in infection prevention and control.||Ensure that the infection control coordinator has completed training to maintain their knowledge of current infection control practices.||PA Low||Reporting Complete||10/10/2016|
|Results of surveillance, conclusions, and specific recommendations to assist in achieving infection reduction and prevention outcomes are acted upon, evaluated, and reported to relevant personnel and management in a timely manner.||Infection control data is collected but is not trended month on month.||Ensure that the infection control data is trended.||PA Low||Reporting Complete||10/10/2016|
|Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer.||(i)Two of five resident files reviewed did not evidence a review of the long-term care plan six monthly. (ii) Three of five files reviewed did not evidence a three monthly review by the GP. (iii) One respite resident with multiple co-morbidities had no assessments or care plan completed on admission (there is no care plan in place 15 days post admission).||i) Ensure that all long-term care plans are reviewed at least six monthly. ii) Ensure that the GP reviews the resident three monthly.||PA Low||Reporting Complete||11/10/2016|
|Service delivery plans demonstrate service integration.||The discharge summary for one resident discharged from hospital requested follow-up blood screening. No evidence could be found that this requirement had been reviewed or implemented.||Ensure that all interventions noted on hospital discharge summaries are reviewed and or actioned.||PA Low||Reporting Complete||11/10/2016|
|The organisation has a clearly defined and documented infection control programme that is reviewed at least annually.||The infection control programme has not been reviewed in the past 12 months.||Ensure that the infection control programme is reviewed at least annually.||PA Low||Reporting Complete||17/10/2016|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||(i)One new resident file did not have a LTCP completed. (ii)One resident file for a resident with a chronic wound did not document the management of continence, nutrition and skin integrity.||(i) Ensure long-term care plans are completed for all residents. (ii) Ensure that interventions are documented for all resident identified needs||PA Moderate||Reporting Complete||04/12/2017|
|Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer.||Five of the five interRAI assessments had not been completed as required (one interRAI assessment was not completed within twenty one days of admission; four had not had interRAI assessments completed six monthly).||Ensure that contractual timeframes around resident assessments and interRAI assessments are met.||PA Moderate||Reporting Complete||20/12/2017|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||There was no documented evidence of the effectiveness of analgesia given for a resident requiring prn analgesia.||Ensure effectiveness of analgesia is documented.||PA Low||Reporting Complete||20/12/2017|
|The organisation has a clearly defined and documented infection control programme that is reviewed at least annually.||The infection control programme has not been reviewed in the last 12 months.||Ensure the infection control programme is reviewed at least annually.||PA Low||Reporting Complete||20/12/2017|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||Discussion around a relative verbal concern was identified in a staff meeting. The verbal concern had not been entered into the complaint register, investigated, followed up and resolved to the satisfaction of the complainant.||Ensure all verbal concerns are managed in line with the complaints procedure.||PA Low||Reporting Complete||11/01/2018|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Internal audits cover all areas of the service. Corrective actions have been identified and documented. There is no documented evidence that corrective actions have been completed and signed off for internal audits with less than 100% compliance. There is no documented evidence that the outcomes of internal audits have been discussed at staff meetings.||Ensure corrective actions are completed and signed off. Ensure outcomes of internal audits are documented in meeting minutes.||PA Low||Reporting Complete||11/01/2018|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||The cooks have completed food safety unit standards. However, other staff involved in food preparation have not completed food safety or chemical safety training. Care staff have not completed skin care, prevention of pressure injuries, restraint minimisation and safe practice within the last two years.||Ensure mandatory education is completed as scheduled.||PA Low||Reporting Complete||11/01/2018|
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: 02 June 2017
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Provisional Audit