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: 10 June 2021

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

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: 10 June 2021

Audit type:Certification Audit

Audit date: 21 May 2018

Audit type:Surveillance Audit

Audit date: 02 June 2016

Audit type:Certification Audit

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