Mary Shapley Rest Home & Hospital

Profile & contact details

Premises details
Premises nameMary Shapley Rest Home & Hospital
Address 4 Spence Lane Whakatane 3120
Total beds78
Service typesGeriatric, Medical, Rest home care
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 2020
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
Websitewww.bupa.co.nz/

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: 18 February 2019

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.(i) One hospital level resident with a stage I pressure injury: the care plan had not been updated to reflect the use of an alternating air wave mattress on bed and gel cushion when sitting in chair. Both pieces of equipment were sighted in use; and (ii) One rest home resident assessed as a high falls risk: the care plan had not been updated to reflect intentional rounding and use of a senor mat implemented as part of the falls prevention strategy. Due to care being implemented and it only bein… (this text has been trimmed due to space limits).(i)-(ii) Ensure care plan is updated when there is a change to resident need. PA LowReporting Complete07/11/2017
The facilitation of safe self-administration of medicines by consumers where appropriate.(i) Two residents who self-administer medications did not have the medications locked securely away. (ii) One resident had not had a documented GP review of the self-medication assessment and consent in the last three months. (i) Ensure that residents who manage their own medication, store the medications securely. (ii) Ensure that the assessment and consent for self-medication is reviewed three monthly. PA ModerateIn Progress
All buildings, plant, and equipment comply with legislation.(i) Hot water temperature has not been well controlled over 2018, despite monthly water temperature testing. The service undertook an analysis of hot water issues and an action plan put in place. At the time of audit this action plan, which included a plumber, was nearing completion, however hot water temperatures for January had not been documented. ii) Hazard registers in place had not all been reviewed since 2017. i) Ensure that hot water temperatures are addressed quickly, and that regular monitoring is documented. ii) Ensure that hazard registers are regularly reviewed and up to date. PA LowIn Progress
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.(i) Neurological observations were not consistently documented according to Bupa policy for two falls which required neurological observations. One did not document any and one had one set of observations taken. (ii) One resident had not been documented as repositioned as per the timeframes on the care plan and one resident with a PEG feed did not have the fluid chart consistently updated. (iii) Short-term care plan developed for wounds were not kept in the resident file alongside the LTCP an… (this text has been trimmed due to space limits).(i) Ensure neurological observations are documented as per Bupa policy. (ii) Ensure that monitoring charts are documented according to timeframes. (iii) Ensure that STCPs are kept in the resident’s individual file alongside the current LTCP and identifies links to current wound management plans. PA LowIn Progress
A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines.(i)Of the ten medication charts reviewed two had a signed paper-based prescription and a non-verified (non-signed) electronic prescription. Both the paper-based and electronic prescriptions matched, however the service was administering and signing for the medication using the (unverified) electronic system. (ii) One resident did not receive medications on the day prior to audit and up until the end if the audit on day two, this was due to the GP not providing a signed prescription chart to the… (this text has been trimmed due to space limits).(i)Ensure that medications are administered from a signed medication chart and that residents have one medication chart. (ii)Ensure that residents are able to be provided with their medications. PA ModerateIn 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. 

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.

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