Profile & contact details
|Premises name||Mossbrae Healthcare|
|Address||48 Argyle Street Mosgiel 9024|
|Service types||Geriatric, Medical, Rest home care|
|Certification/licence name||Mossbrae Healthcare Limited - Mossbrae Healthcare|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||19 June 2020|
|Certification period||36 months|
|Provider name||Mossbrae Healthcare Limited|
|Street address||48 Argyle Street Mosgiel 9024|
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: 07 November 2018
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Each episode of restraint is documented in sufficient detail to provide an accurate account of the indication for use, intervention, duration, its outcome, and shall include but is not limited to: (a) Details of the reasons for initiating the restraint, including the desired outcome; (b) Details of alternative interventions (including de-escalation techniques where applicable) that were attempted or considered prior to the use of restraint; (c) Details of any advocacy/support offered, provided o… (this text has been trimmed due to space limits).||(i) Five of seven restraint care plans reviewed do not document the frequency of monitoring required when restraint is in use. (ii) Monitoring of restraints when in use is not consistently documented.||(i) and (ii) Ensure the frequency of monitoring required when restraint is in use is documented in the care plans and ensure that restraint monitoring occurs within the designated timeframes and that this is documented.||PA Low||Reporting Complete||17/08/2017|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Internal audit results that identify areas of non-compliance do not consistently include a corrective action plan.||Ensure corrective action plans are completed and evaluated to demonstrate achievement of compliance with the desired outcome||PA Low||Reporting Complete||07/11/2017|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||(i) Fridge temperatures are not evidenced to be consistently recorded. (ii) Food found in fridges is covered but not dated. (iii) Decanted dry food stores are labelled but do not document an expiry date.||(i) Ensure fridge temperatures are recorded as per policy. (ii) Ensure all food is labelled and dated. (iii) Ensure all decanted food has an expiry date documented.||PA Low||Reporting Complete||07/11/2017|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||The service has experienced delays in accessing InterRAI training for registered nursing staff, therefore InterRAI assessments have not been completed within the required timeframes.||Ensure InterRAI training is accessed to enable registered nurses to complete assessments within the required timeframes.||PA Negligible||Reporting Complete||16/02/2018|
|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.||Seven of sixteen medication signing sheets identify that medication has not always been signed as administered.||Ensure medication signing sheets document the administration of prescribed medications.||PA Moderate||Reporting Complete||16/02/2018|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||(i) One resident with challenging behaviour did not have de-escalation techniques documented to support all behaviours that challenge. (ii) One resident with an indwelling catheter did not have interventions documented to manage all aspects of catheter care. (iii) Two residents with weight loss did not have interventions documented to support management of the weight loss.||Ensure that long-term care plans include interventions to manage and support all assessed needs||PA Moderate||Reporting Complete||16/02/2018|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i) Four of eight wound assessment, treatment and evaluation forms do not document achievement towards the wound healing process with each dressing change. (ii) Three of eight wound charts have multiple wounds documented on one assessment chart. (iii) Monitoring charts were not evidenced in use to reflect food and fluid intake for those identified at risk of malnutrition or record the frequency of pressure injury prevention interventions implemented. This information was also not documented … (this text has been trimmed due to space limits).||(i) Ensure the plan for each wound monitors progress towards the wound healing process. (ii) Ensure all wounds are assessed individually and documented on an assessment form per wound. (iii) Ensure monitoring charts or progress notes are completed to reflect monitoring and implemented care.||PA Moderate||Reporting Complete||19/02/2018|
|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) Eight of twelve GP standing orders were not dated. ii) Two of ten medication signing sheets identified that medication has not always been signed as administered. iii) Three of ten ‘as required’ medications did not include the reason for administration (including the respite file). iv) The temperature of the medication fridges is not consistently documented. v) The controlled drug register did not include the time of administration for four entries. vi) The assessment of the one self-me… (this text has been trimmed due to space limits).||i) Ensure standing orders are reviewed, signed and dated annually. ii) Ensure medication signing sheets document the administration of prescribed medications. iii) Ensure all ‘as required’ medications include a reason for administration. iv) Document medication fridge temperatures daily as per policy. v) Ensure the controlled drug register includes the time of administration. vi) Ensure self-medicating residents are assessed for competency six-monthly as per policy.||PA Moderate||Reporting Complete||11/03/2019|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||There is no documented evidence of discussion of survey results and related corrective actions discussed at staff meetings||Ensure staff are informed of survey results and corrective actions||PA Low||Reporting Complete||08/04/2019|
|The appointment of appropriate service providers to safely meet the needs of consumers.||Reference checks are verbal but not documented.||Document reference checks and keep on file.||PA Low||Reporting Complete||22/05/2019|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||The service has not provided training around falls prevention, abuse and neglect, culture, pressure injury prevention, challenging behaviours in the last two years. An education session is planned for the end of the year.||Ensure all compulsory education is provided.||PA Low||Reporting Complete||22/05/2019|
|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.||i) An initial assessment and care plan were not completed for the respite resident within required timeframes. ii) Ongoing interRAI assessments were not completed six monthly for three of four long-term residents. iii) Evaluations have not always been completed six monthly.||i) Ensure all initial assessments are completed within 24 hours and initial care plans within 48 hours of admission. ii) Ensure interRAI assessments are reviewed at least six monthly or sooner for changes in health. iii) Ensure long-term care plans are evaluated six monthly.||PA Moderate||Reporting Complete||22/05/2019|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||(i) Two residents (one hospital and one RH) with a history of falls did not include all interventions or strategies required to minimise the risk. (ii) One hospital respite resident with pain did not include interventions to manage all aspects of pain relief. (iii) One hospital resident with weight loss did not have interventions documented to support nutritional needs. (iv) One hospital resident using an enabler (bedrails) did not document the associated risks.||(i) – (iv) Ensure that long-term care plans include interventions to manage and support all assessed needs.||PA Moderate||Reporting Complete||22/05/2019|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i) Three of eight wound assessment, treatment and evaluation forms do not document achievement towards the wound healing process with each dressing change. (ii) Five of eight wound were not redressed at the documented frequency. iii) One resident using an enabler had not been reviewed six monthly.||(i) Ensure the plan for each wound monitors progress towards the wound healing process. (ii) Ensure all wounds are redressed at the frequency documented on the wound management plan. iii) Ensure all residents using enablers or restraint are reviewed at least six monthly.||PA Moderate||Reporting Complete||22/05/2019|
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: 07 November 2018
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit