Lyndale Villa

Profile & contact details

Premises details
Premises nameLyndale Villa
Address 52 Cole Street Masterton 5810
Total beds36
Service typesRest home care
Certification/licence details
Certification/licence nameLyndale Care Limited - Lyndale Villa and Manor
Current auditorThe DAA Group Limited
End date of current certificate/licence23 November 2026
Certification period36 months
Provider details
Provider nameLyndale Care Limited
Street addressLyndale Villa and Lyndale Manor 52 Cole Street Masterton 5810
Post address52 Cole Street Masterton 5810

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: 13 September 2023

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Service providers shall evaluate progress against quality outcomes.Internal audits and incident reporting processes are not being completed to evaluate progress against quality outcomes. Provide evidence that internal audits and incident reporting processes are being completed to evaluate progress and improve quality outcomes. PA ModerateIn Progress
Meaningful activities shall be planned and facilitated to develop and enhance people’s strengths, skills, resources, and interests, and shall be responsive to their identity.Meaningful activities that focussed on resident’s previous lifestyle patterns and enhanced residents’ strengths, skills, and interests were not offered in the secure dementia unit. Provide evidence meaningful activities are provided in the secure dementia unit that enhance residents’ strengths, skills, and interests. Provide evidence that the programme is overseen or implemented by a person skilled in assessment, implementation, and evaluation of diversional and motivational recreation. PA ModerateIn Progress
There is an IP role, or IP personnel, as is appropriate for the size and the setting of the service provider, who shall: (a) Be responsible for overseeing and coordinating implementation of the IP programme; (b) Have clearly defined responsibility for IP decision making; (c) Have documented reporting lines to the governance body or senior management; (d) Follow a documented mechanism for accessing appropriate multidisciplinary IP expertise and advice when needed; (e) Receive continuing education… (this text has been trimmed due to space limits).There was no evidence to verify the ICO had completed continuing education on IPC and AMS. Provide evidence the ICO has completed continuing education in IPC and AMS. PA LowIn Progress
Governance bodies shall have meaningful Māori representation on relevant organisational boards, and these representatives shall have substantive input into organisational operational policies.Lyndale has no formal alliances with Māori to support meaningful input into organisational policy and plans for Māori in the service. Provide evidence that formal alliances with Māori to support meaningful input into organisational policy and plans for Māori in the service have been established. PA LowIn Progress
Fundamental to the development of a care or support plan shall be that: (a) Informed choice is an underpinning principle; (b) A suitably qualified, skilled, and experienced health care or support worker undertakes the development of the care or support plan; (c) Comprehensive assessment includes consideration of people’s lived experience; (d) Cultural needs, values, and beliefs are considered; (e) Cultural assessments are completed by culturally competent workers and are accessible in all settin… (this text has been trimmed due to space limits).Cultural and lifestyle assessments have not been completed for residents residing in the secure dementia unit and neurological observations are not being completed for residents who have had an unwitnessed fall. Provide evidence the required cultural and lifestyle assessments are completed for residents in the secure dementia unit and that neurological assessments are being completed for all residents’ who have had an unwitnessed fall. PA ModerateReporting Complete06/03/2024
The nutritional value of menus shall be reviewed by appropriately qualified personnel such as dietitians.The present menu is currently being reviewed by a dietician; however, the menu at this time has not been reviewed since July 2021. Provide evidence the menu has been reviewed by the dietician. PA LowReporting Complete06/03/2024
In implementing care or support plans, service providers shall demonstrate: (a) Active involvement with the person receiving services and whānau; (b) That the provision of service is consistent with, and contributes to, meeting the person’s assessed needs, goals, and aspirations. Whānau require assessment for support needs as well. This supports whānau ora and pae ora, and builds resilience, self-management, and self-advocacy among the collective; (c) That the person receives services that remov… (this text has been trimmed due to space limits).The documentation of care requirements in the care plans of residents in the Manor were not always consistent with meeting the residents’ assessed needs. Provide evidence the documentation in the care plan of residents in the Manor is consistent with meeting the residents’ assessed needs. PA ModerateReporting Complete06/03/2024
Service providers shall evaluate progress against quality outcomes.Internal audits and incident reporting processes are not being completed to evaluate progress against quality outcomes. Provide evidence that internal audits and incident reporting processes are being completed to evaluate progress and improve quality outcomes. PA ModerateIn Progress
Meaningful activities shall be planned and facilitated to develop and enhance people’s strengths, skills, resources, and interests, and shall be responsive to their identity.Meaningful activities that focussed on resident’s previous lifestyle patterns and enhanced residents’ strengths, skills, and interests were not offered in the secure dementia unit. Provide evidence meaningful activities are provided in the secure dementia unit that enhance residents’ strengths, skills, and interests. Provide evidence that the programme is overseen or implemented by a person skilled in assessment, implementation, and evaluation of diversional and motivational recreation. PA ModerateIn Progress
There is an IP role, or IP personnel, as is appropriate for the size and the setting of the service provider, who shall: (a) Be responsible for overseeing and coordinating implementation of the IP programme; (b) Have clearly defined responsibility for IP decision making; (c) Have documented reporting lines to the governance body or senior management; (d) Follow a documented mechanism for accessing appropriate multidisciplinary IP expertise and advice when needed; (e) Receive continuing education… (this text has been trimmed due to space limits).There was no evidence to verify the ICO had completed continuing education on IPC and AMS. Provide evidence the ICO has completed continuing education in IPC and AMS. PA LowIn Progress
Governance bodies shall have meaningful Māori representation on relevant organisational boards, and these representatives shall have substantive input into organisational operational policies.Lyndale has no formal alliances with Māori to support meaningful input into organisational policy and plans for Māori in the service. Provide evidence that formal alliances with Māori to support meaningful input into organisational policy and plans for Māori in the service have been established. PA LowIn Progress
Fundamental to the development of a care or support plan shall be that: (a) Informed choice is an underpinning principle; (b) A suitably qualified, skilled, and experienced health care or support worker undertakes the development of the care or support plan; (c) Comprehensive assessment includes consideration of people’s lived experience; (d) Cultural needs, values, and beliefs are considered; (e) Cultural assessments are completed by culturally competent workers and are accessible in all settin… (this text has been trimmed due to space limits).Cultural and lifestyle assessments have not been completed for residents residing in the secure dementia unit and neurological observations are not being completed for residents who have had an unwitnessed fall. Provide evidence the required cultural and lifestyle assessments are completed for residents in the secure dementia unit and that neurological assessments are being completed for all residents’ who have had an unwitnessed fall. PA ModerateReporting Complete06/03/2024
The nutritional value of menus shall be reviewed by appropriately qualified personnel such as dietitians.The present menu is currently being reviewed by a dietician; however, the menu at this time has not been reviewed since July 2021. Provide evidence the menu has been reviewed by the dietician. PA LowReporting Complete06/03/2024
In implementing care or support plans, service providers shall demonstrate: (a) Active involvement with the person receiving services and whānau; (b) That the provision of service is consistent with, and contributes to, meeting the person’s assessed needs, goals, and aspirations. Whānau require assessment for support needs as well. This supports whānau ora and pae ora, and builds resilience, self-management, and self-advocacy among the collective; (c) That the person receives services that remov… (this text has been trimmed due to space limits).The documentation of care requirements in the care plans of residents in the Manor were not always consistent with meeting the residents’ assessed needs. Provide evidence the documentation in the care plan of residents in the Manor is consistent with meeting the residents’ assessed needs. PA ModerateReporting Complete06/03/2024

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: 13 September 2023

Audit type:Certification Audit

Audit date: 19 October 2021

Audit type:Surveillance Audit

Audit date: 18 September 2019

Audit type:Certification Audit

Audit date: 25 March 2019

Audit type:Surveillance Audit

Audit date: 05 July 2018

Audit type:Partial Provisional Audit; Surveillance Audit

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