Mary Shapley Rest Home & Hospital

Profile & contact details

Premises details
Premises nameMary Shapley Rest Home & Hospital
Address 4 Spence Lane Whakatane 3120
Total beds79
Service typesRest home care, Geriatric, Medical
Certification/licence details
Certification/licence nameBupa Care Services NZ Limited - Mary Shapley Rest Home & Hospital
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence23 June 2024
Certification period36 months
Provider details
Provider nameBupa Care Services NZ Limited
Street addressLevel 2 109 Carlton Grove Road Newmarket Auckland 1023
Post addressPO Box 113054 Newmarket Auckland 1149

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: 22 November 2022

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Evidence of annual performance appraisals were missing in all four staff files of staff who have been employed for over one year. Ensure performance appraisals are completed annually, in line with the organisation’s policies and procedures. PA LowReporting Complete09/05/2023
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.(i) Quality data that is being collected and collated (e.g., falls, skin tears, bruising, infections) is not being trended, analysed or communicated to staff. (ii) Internal audit results with associated corrective actions (if any) are not included in the quality meeting minutes. (iii) The two-monthly quality meeting minutes for April 2021 indicated that no complaints had been received over the preceding two months, but in fact four complaints had been received (three in February and one in M… (this text has been trimmed due to space limits).(i) Ensure quality data that is collected and collated is trended and analysed with results communicated to staff. (ii) Ensure internal audit results with associated corrective actions (if any) are communicated to staff. (iii) Ensure complaints received are included in the quality meeting minutes. PA LowReporting Complete09/05/2023
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.Neurological observations were not consistently documented according to Bupa policy for eight of eleven falls which required neurological observations. Three did not document any and five did not have full sets of observations taken. This is a moderate finding as had been a shortfall in the last surveillance audit. Ensure neurological observations are documented as per Bupa policy. PA ModerateReporting Complete09/05/2023
An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.Two of four complaints lodged were missing documented evidence of the complainant being informed of the outcome of the complaint. Ensure there is documented evidence to support complainants are informed of the outcome of their complaint. PA ModerateReporting Complete09/05/2023
Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care.Quality data, including internal audit results and clinical indicators are collected, have trend analysis, and results are shared with staff when meetings occur; however, between January and November 2022 meetings have not been held regularly as scheduled. Ensure meetings occur as scheduled PA LowReporting Complete30/01/2024
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). Three resident files evidenced that a GP had not seen the resident within five days of admission (eight, fifteen and twenty-eight days late). (ii). One LTCP was not completed within 21 days (over three weeks overdue). (i). Ensure residents are seen by their GP within five days of admission. (ii). Ensure LTCP’s are completed within the 21- day timeframe PA LowReporting Complete30/01/2024
Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services.The service does not have sufficient numbers of registered nurses to have an RN on duty at all times as per the ARC contract D17.4 a. i. Ensure a registered nurse is on duty at all times to meet the requirements of the ARC contract D17.4 a. i. PA LowReporting Complete20/02/2024

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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