Marire Rest Home
Profile & contact details
| Premises name | Marire Rest Home |
|---|---|
| Address | 31 Page Street Stratford 4332 |
| Total beds | 29 |
| Service types | Rest home care |
| Certification/licence name | Age Care Central Limited - Marire Rest Home |
|---|---|
| Current auditor | The DAA Group Limited |
| End date of current certificate/licence | 30 April 2020 |
| Certification period | 36 months |
| Provider name | Age Care Central Limited |
|---|---|
| Street address | 59 Brecon Road Stratford 4332 |
| Post address | PO Box 318 Stratford 4352 |
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: 31 October 2018
| Outcome required | Found at audit | Action required | Risk rating | Action status | Date action reported complete |
|---|---|---|---|---|---|
| Advance directives that are made available to service providers are acted on where valid. | Two of six files sampled contained advance directives that were not valid. The two forms had been signed by the GP that the resident was not competent to make an advance directive and was documented as ‘not for resuscitation’, but there was no indication that this was a clinically-indicated decision. | Ensure that all advance directives are valid. | PA Low | Reporting Complete | 18/05/2017 |
| 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. | (i) Three of six files did not have an interRAI assessment within 21 days of admission. (ii) One resident who had previously had respite care did not have the initial assessment updated when they were admitted. (iii) Four resident files sampled were not reviewed by the GP within two working days of admission. (iv) One resident had not been reviewed by the GP three-monthly. (v) Three resident files had not had regular six-monthly care plan evaluations completed. | Ensure contractual timeframes around clinical assessments, plans and evaluations are met. | PA Moderate | Reporting Complete | 19/06/2017 |
| A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented. | Internal audits completed in regards to clinical areas did not all evidence corrective actions being documented where improvements were identified. | Ensure the quality improvement programme for clinical includes evidence of corrective action plans where improvements are identified and evidence that corrective actions are implemented. | PA Low | Reporting Complete | 19/06/2017 |
| The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes. | (i) The three current wounds that commenced before 31 January 2017 did not have dressings or reviews documented between 31 January 2017 and 12 February 2017. (ii) Caregivers who complete wound dressings have not had recent training around this. (iii) Neurological observations were not completed for the one resident incident form sampled where a head injury had occurred. | (i) Ensure that all wounds are reviewed regularly and these are documented. (ii) Ensure caregivers who complete dressings are trained to do so. (iii) Ensure neurological observations are completed when a resident has a suspected head injury. | PA Moderate | Reporting Complete | 17/07/2017 |
| Consumers have a right to full and frank information and open disclosure from service providers. | Five of fifteen accident/incident forms and associated progress notes failed to indicate that families were informed following an adverse event. | Ensure documentation evidences families (and/or EPOA) being kept informed following an adverse event. | PA Low | Reporting Complete | 17/07/2017 |
| Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process. | Five of six resident care plans sampled did not have all identified needs addressed. | Ensure all care plans address all identified resident needs. | PA Moderate | Reporting Complete | 02/08/2017 |
| Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers. | Clinical data collected is not routinely analysed to identify trends. Clinical outcomes have not been communicated and shared with the care staff on a regular basis. | Ensure quality data is regularly analysed with trends identified. Ensure care staff are kept informed regarding internal audit results. | PA Low | Reporting Complete | 02/08/2017 |
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: 31 October 2018Audit type:Surveillance Audit
Audit date: 20 February 2017Audit type:Certification Audit
Audit date: 22 September 2015Audit type:Surveillance Audit
Audit date: 19 March 2014Audit type:Certification Audit
Audit date: 12 June 2013Audit type:Surveillance Audit
Audit date: 23 February 2012Audit type:Certification Audit