Profile & contact details
|Premises name||Maygrove Lifecare|
|Address||112 Riverside Road Orewa 0931|
|Service types||Rest home care|
|Certification/licence name||Heritage Lifecare Limited - Maygrove Lifecare|
|Current auditor||The DAA Group Limited|
|End date of current certificate/licence||31 March 2021|
|Certification period||36 months|
|Provider name||Heritage Lifecare Limited|
|Street address||Level 2 111 Johnsonville Road Johnsonville Wellington 6037|
|Post address||PO Box 13223 Johnsonville Wellington 6440|
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: 21 November 2019
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||The complaints register does not include details of all complaints received. Complaints related documentation (either the complaint or response) was not available for review for some sampled complaints.||Ensure the complaints register includes details of all complaints and that appropriate records are consistently available related to each complaint.||PA Low||Reporting Complete||26/05/2020|
|There is a document control system to manage the policies and procedures. This system shall ensure documents are approved, up to date, available to service providers and managed to preclude the use of obsolete documents.||The policy and procedure manuals are in the care home manager’s office and are not accessible to staff when the care home manager or registered nurse are not on site. The hazard register could not be located. Since July 2019, only one staff member has read and signed as having read one set of updated policies / procedures in variance to the organisation’s requirements.||Ensure policies and procedures and the hazard register are available for staff to access when required. Staff consistently read updated policies/procedures and sign that this has occurred.||PA Low||Reporting Complete||26/05/2020|
|A process to measure achievement against the quality and risk management plan is implemented.||Internal audits have not been undertaken since 1 August 2019. The resident, relative and staff satisfaction surveys were conducted earlier in 2019. The results have not been evaluated as yet or communicated to Maygrove Lifecare. Incidents are being reported and included as part of the Heritage Lifecare indicator reporting programme. However, there is not a consistent process of filing these documents to ensure all reported events are included.||Undertake internal audits as scheduled. Evaluate and report the results of the resident, relative and staff satisfaction surveys conducted in early 2019. Ensure all completed incidents reports are filed in a logical manager to ensure the accuracy of the quality indicator data.||PA Low||Reporting Complete||26/05/2020|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Corrective actions plans are not consistently developed when areas for improvement have been identified. This includes in response to internal audits or complaints. When action plans are developed, there is limited evidence that all required actions have been implemented and monitored for effectiveness.||Consistently develop corrective actions plans when areas for improvement are identified. Implement a process to monitor that corrective actions have been undertaken and assess their effectiveness.||PA Moderate||Reporting Complete||26/05/2020|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||While staff interviewed advise they are provided with an orientation relevant to their role, records verifying completion were not sighted in three out of three staff files sampled for staff employed in July 2019 and August 2019.||Maintain records to demonstrate that new staff complete orientation requirements in a timely manner.||PA Low||Reporting Complete||26/05/2020|
|Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer.||The RN responsible for the interRAI assessments was interviewed. The current resident interRAI assessments and care plan reviews are not being completed within the required timeframes. Five resident interRAI assessments were overdue. Four of the five were two months overdue and one interRAI was one month overdue. The care plans reviewed were not consistently updated with the required interventions to meet the assessed needs/goals set for all individual residents.||Ensure the interRAI re-assessments are completed within the required timeframes and that the care plans are updated appropriately to ensure they are current, up-to-date and available to guide care staff.||PA Low||Reporting Complete||27/07/2020|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||There is a staff ongoing education and competency assessment programme. Records verifying applicable staff have completed the required competencies were not available for review during audit. Staff training is not consistently occurring as planned. Topics that have not been included in the timeframes required by HLL included sexuality / intimacy, privacy and confidentiality, emergency management including civil defence, behaviours that challenge, informed consent, enduring power of attorney and … (this text has been trimmed due to space limits).||Provide education in accordance with Maygrove Lifecare (Heritage Lifecare Limited) staff education programme. Maintain records to demonstrate staff have completed the competency requirements as required by Heritage Lifecare Limited.||PA Low||Reporting Complete||25/08/2020|
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: 21 November 2019
Audit type:Surveillance Audit
Audit type:Certification Audit