Marne Street Hospital
Profile & contact details
| Premises name | Marne Street Hospital |
|---|---|
| Address | 7 Marne Street Andersons Bay Dunedin 9013 |
| Total beds | 55 |
| Service types | Medical, Physical, Intellectual, Rest home care, Geriatric |
| Certification/licence name | Marne Street Hospital Limited - Marne Street Hospital |
|---|---|
| Current auditor | Health and Disability Auditing New Zealand Limited |
| End date of current certificate/licence | 13 December 2024 |
| Certification period | 36 months |
| Provider name | Marne Street Hospital Limited |
|---|---|
| Street address | 7 Marne Street Andersons Bay Dunedin 9013 |
| Post address |
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: 11 April 2023
| Outcome required | Found at audit | Action required | Risk rating | Action status | Date action reported complete |
|---|---|---|---|---|---|
| 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). One hospital level resident interRAI assessment had not been completed within 21 days of admission. ii). Two hospital level residents had not had their long-term care plan developed within 21 days of admission | i). and ii) Ensure that all assessments and care plans are completed within the required timeframes | PA Low | Reporting Complete | 10/01/2022 |
| Each episode of restraint is documented in sufficient detail to provide an accurate account of the indication for use, intervention, duration, its outcome, and shall include but is not limited to: (a) Details of the reasons for initiating the restraint, including the desired outcome; (b) Details of alternative interventions (including de-escalation techniques where applicable) that were attempted or considered prior to the use of restraint; (c) Details of any advocacy/support offered, provided o… (this text has been trimmed due to space limits). | The files of three residents using restraint (sample size extended) did not consistently indicate regular (two-hourly) monitoring while the restraint was in use. | Ensure the frequency of monitoring restraint while in use follows the monitoring requirements as determined in the restraint assessment and resident care plan. | PA Low | Reporting Complete | 11/01/2022 |
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | The transfer policy did not fully document the requirements on maintaining the ceiling hoists. | Ensure to review transfer policy to include different transfer equipment/ceiling hoists/ risks/requirements for annual maintenance of ceiling hoists. | PA Moderate | Reporting Complete | 09/11/2023 |
| 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. | Two residents (YPD and LTC-CHC) did not have a current long-term care plan in place. These have not been completed in a timely manner. | Ensure long-term care plans are developed within a timely manner for non-ARRC residents. | PA Moderate | Reporting Complete | 09/11/2023 |
| Surveillance methods, tools, documentation, analysis, and assignment of responsibilities shall be described and documented using standardised surveillance definitions. Surveillance includes ethnicity data. | Ethnicity data is not collected as part of surveillance data. | Ensure ethnicity data is included as part of surveillance. | PA Low | Reporting Complete | 09/11/2023 |
| Each episode of restraint shall be documented on a restraint register and in people’s records in sufficient detail to provide an accurate rationale for use, intervention, duration, and outcome of the restraint, and shall include: (a) The type of restraint used; (b) Details of the reasons for initiating the restraint; (c) The decision-making process, including details of de-escalation techniques and alternative interventions that were attempted or considered prior to the use of restraint; (d) If … (this text has been trimmed due to space limits). | (i). One YPD resident had multiple restraints recorded on one form; however, the form only reflects risks related to when they are seated and not when in bed. (ii). One hospital resident’s monitoring chart did not state the frequency required on the chart. (iii). Monitoring charts for the two residents related to a lap belt and bedrail use has not occurred within the timeframe stated in the care plan. | (i)-(ii). Ensure each episode of type of restraint shall be recorded/ monitored in sufficient detail to provide an accurate rationale for use, intervention, duration, and outcome of restraint. (iii). Ensure monitoring charts are fully completed to guide staff in the frequency required. | PA Moderate | Reporting Complete | 09/11/2023 |
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.
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.
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 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) 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: 11 April 2023Audit type:Surveillance Audit
Audit date: 07 October 2021Audit type:Certification Audit
Audit date: 05 November 2019Audit type:Surveillance Audit
Audit date: 19 September 2017Audit type:Certification Audit