Masonic Court Rest Home and Hospital
Profile & contact details
|Premises name||Masonic Court Rest Home and Hospital|
|Address||13 Clausen Street Takaro Palmerston North 4412|
|Service types||Rest home care, Geriatric, Medical|
|Certification/licence name||Masonic Care Limited - Masonic Court Rest Home and Hospital|
|Current auditor||The DAA Group Limited|
|End date of current certificate/licence||14 September 2019|
|Certification period||36 months|
|Provider name||Masonic Care Limited|
|Street address||63 Wai-Iti Crescent Woburn Lower Hutt 5010|
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: 23 June 2016
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|The appointment of appropriate service providers to safely meet the needs of consumers.||(i)Four of six files had no evidence of current performance appraisals. The other two files were for employees who are new and appraisals are not due. (ii) None of the eight staff files reviewed had evidence of police vetting.||All staff are have current performance appraisals. Police vetting is undertaken as part of the recruitment process.||PA Moderate||Reporting Complete||13/12/2016|
|Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome.||Resident progress towards meeting desired outcomes identified in short-term care plans was not consistently documented.||Residents’ progress towards meeting desired outcomes is fully documented.||PA Moderate||Reporting Complete||13/12/2016|
|Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include: (a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk; (b) A process that addresses/treats the risks associated with service provision is developed and im… (this text has been trimmed due to space limits).||There is no register for actual hazards. Hazards are being entered into the maintenance book by staff, instead of staff completing hazard forms. The health and safety officer reported they had not seen any completed hazard forms for some time.||Provide evidence that all hazards are reported on a hazard form. Record all actual hazards on a register so they are able to be managed, monitored, evaluated and reviewed on a regular basis.||PA Moderate||Reporting Complete||13/12/2016|
|Where progress is different from expected, the service responds by initiating changes to the service delivery plan.||Short-term care plans were not consistently or comprehensively developed to reflect acute changes in the health status of residents.||When resident progress is different from expected, the resident’s care plan is updated to reflect this.||PA Moderate||Reporting Complete||13/12/2016|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||Interventions documented in short term care plans were not consistently implemented.||Interventions detailed within care plans are fully implemented.||PA Moderate||Reporting Complete||13/12/2016|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Corrective action plans are not always developed following deficits identified. Where corrective action plans have been developed, there was no review to determine whether the corrective action had been effective.||Develop and implement corrective action plans for all deficits identified and review the effectiveness.||PA Low||Reporting Complete||13/12/2016|
|Results of surveillance, conclusions, and specific recommendations to assist in achieving infection reduction and prevention outcomes are acted upon, evaluated, and reported to relevant personnel and management in a timely manner.||Infection surveillance is not integrated across the facility, and there is limited analysis of some surveillance data.||Infection surveillance is integrated across the facility, and all surveillance data is fully analysed and evaluated.||PA Low||Reporting Complete||13/12/2016|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Although staff reported they discuss analysis and trends during their staff meetings, there was no documented evidence that clinical indicators are analysed to identify any trends. Meeting minutes evidenced numbers only are reported back to staff, apart from falls with injury or without injury.||Provide documented evidence that quality data is analysed to identify trends and that this is reported back to staff.||PA Low||Reporting Complete||13/12/2016|
|Each episode of restraint is evaluated in collaboration with the consumer and shall consider: (a) Future options to avoid the use of restraint; (b) Whether the consumer's service delivery plan (or crisis plan) was followed; (c) Any review or modification required to the consumer's service delivery plan (or crisis plan); (d) Whether the desired outcome was achieved; (e) Whether the restraint was the least restrictive option to achieve the desired outcome; (f) The duration of the restraint episode… (this text has been trimmed due to space limits).||Evaluation forms are basic and do not include items (a) to (k) under this criterion.||Develop and implement an evaluation form that includes (a) to (k) as required under this criterion.||PA Low||Reporting Complete||07/03/2017|
|The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.||The maintenance person reported they undertake preventative maintenance, however there is no programme available. There are some external doors and weather boards with dry rot. Windows with wooden surrounds have the putty missing around the frames.||Develop and implement a proactive maintenance programme, and provide timeframes for replacing/maintaining the external doors, weatherboards, and window frames to an adequate standard.||PA Low||Reporting Complete||07/03/2017|
The outcome required by the Health and Disability Services Standards.
Found at audit
The issue that was found when the rest home was audited.
The action necessary to fix the issue, as decided by the auditor.
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.
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.
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.
Audit reportsAudit date: 23 June 2016
Audit type:Certification Audit