Maryann Rest Home and Hospital
Profile & contact details
Premises name | Maryann Rest Home and Hospital |
---|---|
Address | 59 Brecon Road Stratford 4332 |
Total beds | 66 |
Service types | Dementia care, Rest home care, Geriatric, Medical |
Certification/licence name | Age Care Central Limited - Maryann Rest Home and Hospital |
---|---|
Current auditor | The DAA Group Limited |
End date of current certificate/licence | 15 May 2024 |
Certification period | 48 months |
Provider name | Age Care Central Limited |
---|---|
Street address | 59 Brecon Road Stratford 4332 |
Post address | PO Box 318 Stratford 4352 |
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: 16 November 2023
Outcome required | Found at audit | Action required | Risk rating | Action status | Date action reported complete |
---|---|---|---|---|---|
Governance bodies shall have demonstrated expertise in Te Tiriti, health equity, and cultural safety as core competencies. | None of the Maryann directors have documented expertise in Te Tiriti o Waitangi, health equity, or cultural competency. | Provide evidence that the governance group for Maryann has documented expertise in Te Tiriti o Waitangi, health equity, and cultural competency. | PA Low | In Progress | |
There shall be a documented pathway for IP and AMS issues to be reported to the governance body at defined intervals, which includes escalation of significant incidents. | Antimicrobial use information is not reported to the board to support the board in their responsibilities in relation to AMS. | Provide evidence that antimicrobial use information is reported to the board to support the board in their responsibilities in relation to AMS. | PA Low | In Progress | |
Where required by legislation, there shall be a Fire and Emergency New Zealand- approved evacuation plan. | FENZ has not approved the fire and emergency evacuation plan for the new wing at Maryann. | Provide evidence that the fire and emergency evacuation scheme has been approved by FENZ prior residents being admitted into the new wing at Maryann. | PA Low | Reporting Complete | 17/01/2024 |
Buildings, plant, and equipment shall be fit for purpose, and comply with legislation relevant to the health and disability service being provided. The environment is inclusive of peoples’ cultures and supports cultural practices. | The service does not yet have a certificate of public use, which will be required prior to residents being accepted into the new wing at Maryann. | Provide evidence of a certificate of public use for the new wing at Maryann prior to resident occupancy. | PA Low | Reporting Complete | 31/01/2024 |
Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided. | Staff employed currently to work in the new wing at Maryann have yet to be orientated to the new wing. Staff employed for the service will need to be orientated to the new wing and the specific services proposed to be provided in the new wing. Competencies for new staff will need to be assessed. | Provide evidence that staff who have already been employed to work in the new wing at Maryann have been orientated to the new wing prior to it being opened. Provide evidence that any new staff employed for the service have been orientated to the service, the specific services proposed to be provided in the new wing, and that the required competencies for new staff have been assessed. | PA Low | Reporting Complete | 31/01/2024 |
There shall be evidence of audit and corrective actions, if applicable, of the appropriate decontamination of reusable medical devices based on recommendations from the manufacturer and best practice standards. | There are no processes in place to audit decontamination of reuseable devices at Maryann. | Provide documentation in relation to processes in place to audit decontamination of reuseable devices at Maryann. | PA Low | Reporting Complete | 13/02/2024 |
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.
Audit reports
Audit date: 16 November 2023Audit type:Partial Provisional Audit
- Maryann Rest Home and Hospital - Nov 2023 (docx, 64.11 KB)
- Maryann Rest Home and Hospital - Nov 2023 (pdf, 163.31 KB)
Audit type:Surveillance Audit
- Maryann Rest Home and Hospital - Feb 2022 (docx, 35.29 KB)
- Maryann Rest Home and Hospital - Feb 2022 (pdf, 139.32 KB)
Audit type:Certification Audit
- Maryann Rest Home and Hospital - Mar 2020 (docx, 47.29 KB)
- Maryann Rest Home and Hospital - Mar 2020 (pdf, 180.22 KB)
Audit type:Surveillance Audit
- Maryann Rest Home and Hospital - Nov 2018 (docx, 34.4 KB)
- Maryann Rest Home and Hospital - Nov 2018 (pdf, 134.66 KB)
Audit type:Certification Audit