Mary Doyle Lifecare

Profile & contact details

Premises details
Premises nameMary Doyle Lifecare
Address 3 Karanema Drive Havelock North 4130
Total beds161
Service typesDementia care, Rest home care, Geriatric, Medical
Certification/licence details
Certification/licence nameMary Doyle Healthcare Limited - Mary Doyle Lifecare
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence21 August 2024
Certification period36 months
Provider details
Provider nameMary Doyle Healthcare Limited
Street address 3 Karanema Drive Havelock North 4130
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: 04 April 2023

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.(i). Nineteen incident forms were sampled where the resident had experienced an unwitnessed fall. RN assessment was documented following the incident however, neurological observations were not completed as per policy for eight falls and only partially completed for nine falls. (ii). One hospital resident with a catheter did not have four hourly output monitoring as detailed in the care plan completed consistently. (iii). One hospital resident did not have vital sign observations taken every … (this text has been trimmed due to space limits).(i)- (iii). Ensure resident monitoring charts are consistently and comprehensively completed as per policy and/or as detailed in their care plan. (v). Ensure interventions clearly cover all assessed needs. PA LowReporting Complete23/05/2022
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Four of 16 staff files did not include a current annual performance appraisal. Ensure that performance appraisals are completed annually as per policy. PA LowReporting Complete23/05/2022
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.i) Corrective action plans are not usually documented when issues are raised in audits or in meetings. ii) There is limited evidence of resolution of issues when raised (e.g., in meeting minutes). i) Ensure that corrective action plans are documented when issues are raised. ii) Ensure that there is resolution of issues documented (e.g., in meeting minutes) when issues are raised. PA LowReporting Complete23/05/2022
Advance directives that are made available to service providers are acted on where valid.The resuscitation status (in the advance directive form) had been authorised by the relative (two written and one verbal – documented in progress notes) for three of the five dementia care files reviewed. Ensure the resuscitation status section of the advance directive form is appropriately signed. PA LowReporting Complete23/05/2022
A medication management system shall be implemented appropriate to the scope of the service.(i)The second signature for medications given in the controlled drug book did not match the signature for the same person on the staff signature log. (ii)There controlled drug book documented a staff member correcting the running total. There was no documented follow up for this issue or incident form. (iii)One midazolam spray was out of date. (iv)There were creams in the medication trolley that had not been dated on opening. (i)-(ii)Ensure that documentation around controlled drug management meets legislative standards. (iii)-(iv)Ensure medications are within date and dated on opening as needed. PA ModerateIn Progress
Service providers shall implement systems to determine and develop the competencies of health care and support workers to meet the needs of people equitably.Restraint competencies have fallen behind since 2022. Ensure restraint competencies are completed as scheduled. PA LowIn Progress
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.(i)Ongoing interRAI reassessments had not always been completed within timeframes for one rest home and one dementia level resident. (ii)The initial interRAI assessment was not completed within timeframes for one hospital level resident. (i)-(ii)Ensure interRAI assessments and reassessments are completed as per required timeframes. PA LowIn Progress
Service providers shall identify external and internal risks and opportunities, including potential inequities, and develop a plan to respond to them.(i). Several corrective action plans have been restarted due to a lack of progress and could not always be signed off. (ii). There was no documented evidence that clinical meetings, staff meetings, and quality improvement/IPC meetings occurred as planned for 2022. (iii). Staff were not always informed of regular quality data trends and analysis, outcomes of the recent staff survey or corrective actions. (i). Ensure corrective actions are documented, implemented, and embedded in practice. (ii). Ensure meetings occur as per the meeting schedule. (iii). Ensure the communication and feedback is provided to staff around quality data and outcomes. PA ModerateIn Progress
Planned review of a person’s care or support plan shall: (a) Be undertaken at defined intervals in collaboration with the person and whānau, together with wider service providers; (b) Include the use of a range of outcome measurements; (c) Record the degree of achievement against the person’s agreed goals and aspiration as well as whānau goals and aspirations; (d) Identify changes to the person’s care or support plan, which are agreed collaboratively through the ongoing re-assessment and review … (this text has been trimmed due to space limits).(i).Two of seven care plans reviewed had not been updated to reflect changes to resident need around mobility (hospital level) and refusal of care (rest home). (ii). One rest home resident returned to the service following a period in Te Whatu Ora secondary level services; there was no documented RN assessment or review of care needs for two-day post admission to the service. (i)-(ii). Ensure care plans are updated to reflect current resident assessed needs. PA ModerateIn Progress
Significant IP events shall be managed using a stepwise approach to risk management and receive the appropriate level of organisational support.(i)There were limited documented evidence of outbreak meetings and lessons learned from outbreaks. (i)Ensure a culture of learning is evident from significant events to promote system change and reduce risks. PA ModerateIn Progress
Health care and support workers shall have the opportunity to discuss and review performance at defined intervals.The appraisal schedule has not been fully implemented. Ensure the appraisal schedule is fully implemented. PA LowIn Progress
Service providers shall facilitate safe self-administration of medication where appropriate.(i)There was no resident assessment and sign off by the GP for self-medication as directed by the service policies. (i)Ensure that self-medicating residents have all appropriate documentation including a GP assessment and sign off PA LowIn Progress
Service providers shall ensure there are safe and effective laundry services appropriate to the size and scope of the health and disability service that include: (a) Methods, frequency, and materials used for laundry processes; (b) Laundry processes being monitored for effectiveness; (c) A clear separation between handling and storage of clean and dirty laundry; (d) Access to designated areas for the safe and hygienic storage of laundry equipment and chemicals. This shall be reflected in a writt… (this text has been trimmed due to space limits).The process of transporting/moving dirty linen within the facility has not been adhered to. Ensure to review and implement the transporting/moving of dirty linen within the facility. PA LowIn Progress
Service providers shall ensure the quality and risk management system has executive commitment and demonstrates participation by the workforce and people using the service.(i)There was no documented evidence of an annual satisfaction survey for 2022. (ii) There was no documented evidence of regular scheduled resident or family/whānau meetings for 2022. (i)-(ii)Ensure residents, family/whānau receiving/involving in the service services are provided an opportunity to give feedback. 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. 

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.

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