Merrivale Rest Home
Profile & contact details
|Premises name||Merrivale Rest Home|
|Address||1 Winger Crescent Kamo 0112|
|Service types||Rest home care, Geriatric, Medical, Dementia care|
|Certification/licence name||Bupa Care Services NZ Limited - Merrivale Rest Home|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||28 February 2020|
|Certification period||36 months|
|Provider name||Bupa Care Services NZ Limited|
|Street address||Level 2 109 Carlton Grove Road Newmarket Auckland 1023|
|Post address||PO 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: 25 July 2018
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|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.||Medication fridge temperatures were not consistently documented in three of three medication fridges in use.||Ensure that medication fridge temperatures are consistently recorded as per policy.||PA Low||Reporting Complete||17/07/2017|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||The food fridges in the kitchenettes in the rest home, hospital and dementia areas did not have date labels on the resident food.||Ensure that all food stored for residents is correctly labelled and dated.||PA Low||Reporting Complete||17/07/2017|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||i) One hospital resident did not have a care plan documented for the management of consistent weight loss (7kg in total since January 2016); and ii) One dementia resident (tracer) did not have a care plan documented for a sudden change in behaviour.||i-ii) Ensure care plan interventions are documented to address all assessed care needs.||PA Low||Reporting Complete||17/07/2017|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||The activities coordinator who works in the dementia unit has been trained to meet the requirements of ARC E4.5 c ii.||Ensure the activity coordinator completes the dementia standards or is a trained in diversional therapy to meet the requirements of ARC E4.5.cii.||PA Low||In Progress|
|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.||Two rest home resident files (sample increased) documented that one initial interRAI was not within 21 days and one interRAI reassessment was not within set timeframes. Two hospital resident files documented that the interRAI reassessment were not within set timeframes.||Ensure that interRAI assessments are documented within set timeframes.||PA Low||In Progress|
|The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.||There was no documented evidence that three rest home care plans, wound care plan/assessments, while written by an experienced enrolled nurse had any RN oversight.||Ensure there is evidence of RN oversite in the rest home||PA Low||In Progress|
|Service delivery plans demonstrate service integration.||One resident had a PI, a complicated abdominal wound and stoma whose treatment included oversight by the stoma nurse and district nurse. The related assessments and care guidance completed by the external RN specialists were not available for staff or included in the care plan.||Ensure resident files and care plans reflect service integration||PA Low||In Progress|
|The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk.||There were four pressure injuries documented though the wound care log including; three at hospital level (two grade two and one grade one) and one grade two in the rest home. The three at hospital level did not have an associated incident form.||Ensure that all pressure injuries are documented as part of the adverse event process.||PA Moderate||Reporting Complete||07/01/2019|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||(i)The one dementia resident care plan reviewed referenced behavioural issues, but there were no interventions to manage triggers, behaviour outburst or to manage the environment. (ii) The two hospital resident care plans reviewed did not fully document all interventions to meet assessed needs. (a) one resident had a short-term care plan for weight loss, but there were no specific interventions documented other to inform next of kin and monitor. (b) one resident care plan did not document the … (this text has been trimmed due to space limits).||(i)- (iii) Ensure that interventions are documented to support all assessed needs.||PA Moderate||Reporting Complete||07/01/2019|
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: 25 July 2018
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Partial Provisional Audit; Verification Audit