Malvina Major Retirement Village

Profile & contact details

Premises details
Premises nameMalvina Major Retirement Village
Address 134 Burma Road Johnsonville Wellington 6037
Total beds150
Service typesRest home care, Geriatric, Medical
Certification/licence details
Certification/licence nameMalvina Major Retirement Village Limited
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence30 October 2018
Certification period36 months
Provider details
Provider nameMalvina Major Retirement Village Limited
Street addressUnit D, Airport Business Park 92 Russley Road Christchurch 8042
Post addressPO Box 771 Christchurch 8140

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: 15 February 2017

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate 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.(i) Three of 22 medication administration signing sheets for packed regular medications have signing gaps. (ii) Eight of 22 medication administration signing sheets have signing gaps for regular non-packaged medications. (iii) There were expired medications in the medication cupboard in the hospital. (iv) Five of 22 medication charts did not evidence three monthly GP reviews. (v) Medication fridge temperatures in the hospital were not consistently recorded weekly. i) and ii) Ensure all medications are signed on the signing sheet when administered. (iii) Ensure there is a system in place for the checking of expiry dates. (iv) Ensure GP reviews medication charts at least three monthly. (v) Ensure fridge temperatures are recorded weekly. PA ModerateReporting Complete17/12/2015
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.Two respite files were reviewed (one rest home and one hospital level of care). (i) The initial care plan for the rest home respite care resident did not include interventions for identified falls risk. The blood sugar levels had not been completed twice daily as instructed on the care plan. (ii) The care plan for the hospital respite care resident had not been reviewed for the current admission to reflect changes in care. (i) Ensure respite care plans are fully completed and reviewed to reflect the resident supports and current health status. (ii) Ensure observations are taken and recorded as instructed on the respite care plan. PA LowReporting Complete06/07/2017
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.Five of ten electronic incident forms sampled did not describe the incident that had occurred and did not document review and analysis to minimise the risk of recurrence. Ensure all reported incidents include a documented description of what occurred and an analysis to minimise the risk of recurrence. PA LowReporting Complete06/07/2017

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. 

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.

Back to top