Springvale Manor Rest Home
Profile & contact details
|Premises name||Springvale Manor Rest Home|
|Address||47 Treadwell Street Springvale Wanganui 4501|
|Service types||Dementia care, Rest home care|
|Certification/licence name||Springvale Manor Limited - Springvale Manor Rest Home|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||01 November 2017|
|Certification period||24 months|
|Provider name||Springvale Manor Limited|
|Street address||47 Treadwell Street Springvale Wanganui 4501|
|Post address||PO Box 7100 Wanganui 4541|
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: 22 November 2016
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||Fridge and freezer temperatures are only recorded monthly. There are insufficient records to evidence that safe food storage has been maintained.||Ensure fridge and freezer temperatures are checked and recorded at least weekly.||PA Moderate||Reporting Complete||22/01/2016|
|Consumers have a right to full and frank information and open disclosure from service providers.||Fifteen incident and accident forms were reviewed. One form evidenced that family had not been notified as per the request from the resident. Three forms had family notification included on them. Eleven of the 15 forms and corresponding resident files did not support that family had been notified of the resident’s incident.||Ensure that family is notified of incidents and accidents in a timely manner.||PA Low||Reporting Complete||22/01/2016|
|The service is able to demonstrate that written consent is obtained where required.||Resuscitation consents were signed by enduring power of attorneys in six of seven files reviewed (rest home and dementia).||Ensure resuscitation consents are signed appropriately.||PA Low||Reporting Complete||22/01/2016|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||InterRAI assessments are not informing the care plans in six of seven care plans reviewed (two rest home and four dementia). One new resident is currently being assessed with the InterRAI tool and has yet to have a long-term care plan developed.||Ensure InterRAI assessments are utilised and include all outcomes in the development of the long-term care plan.||PA Low||Reporting Complete||22/01/2016|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Since the previous audit, the staff meeting minute’s template has been changed and the new template includes all quality activities and a space for follow up actions and date. Following a review of the January to June 2015 meeting minutes, it revealed that meeting minutes did not include discussion around quality data or what actions were required by staff for the quality improvement. Staff interviewed confirmed that the RN and the owner/manager proactively manage any risk related to the resid… (this text has been trimmed due to space limits).||Ensure that meeting minutes include discussion of quality data and actions required, if any.||PA Low||Reporting Complete||22/01/2016|
|The organisation is managed by a suitably qualified and/or experienced person with authority, accountability, and responsibility for the provision of services.||The owner/manager did not have documented evidence of at least eight hours of professional development activities annually related to managing a rest home.||Provide evidence that the manager of Springvale Manor has completed at least eight hours of professional development activity related to managing a rest home.||PA Low||Reporting Complete||22/01/2016|
|The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code.||A complaint was received on 14 April 2015, which had not been acknowledged or recorded in the complaint register in a timely manner. There was no documented evidence of acknowledgment letter to the complainant. The complaint was forwarded to the local DHB and the MOH Health Cert team. The complaint was investigated by the owner/manager and a letter dated 22 June 2015 was sent to the complainant which detailed the outcome of the investigation. The resolution of the complaint was not documente… (this text has been trimmed due to space limits).||Ensure that complaint management policies and procedures are implemented, complaints are acknowledged and resolution of the complaint is recorded in the register.||PA Low||Reporting Complete||22/01/2016|
|The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.||Two residents in the dementia unit were observed to be immobile and requiring a higher level of care. On discussion with the registered nurse, it was noted that no reassessment has been conducted or referral made for alternative level of care.||Ensure residents are referred for reassessment when required.||PA Moderate||Reporting Complete||29/02/2016|
|Entry criteria, assessment, and entry screening processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies.||The seven admission agreements sighted had all been signed within the required timeframe. Exclusions from the service are included in the admission agreement but the current contract does not include the required addition to the contract as of 1 July 2015. One resident admission after 1 July 2015 did not include the amendments to the DHB contract.||Ensure that the admission agreement aligns with the DHB contract.||PA Low||Reporting Complete||01/03/2016|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||i)Two of 13 home assistants who work in the dementia unit have not completed required dementia training after a year of their employment; ii) the cook has not completed food safety and hygiene standards training.||i) Provide evidence that all home assistants who work in the dementia unit have completed the required unit standards within one year of employment; and ii) provide evidence that the cook has completed safe food handling training.||PA Moderate||Reporting Complete||01/03/2016|
|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.||i) One of 15 incident forms evidence that the resident had sustained a potential head injury following a fall. There was no record of follow up after the incident and no neurological observations were completed or documented; ii) One of 15 forms did not evidence that follow up was conducted of an incident where a resident hit another resident.||i)Ensure that all clinical care is provided to residents following incidents and injury including neurological observations; ii) ensure that appropriate nursing assessment and monitoring is conducted for residents following behaviour related incidents.||PA Moderate||Reporting Complete||01/03/2016|
|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.||Nineteen incident forms were reviewed for October and November 2016. There were four forms reviewed of residents who had unwitnessed falls in the dementia unit. There were no records of neurological observations completed or documented for these residents.||Ensure that neurological observations are documented and completed for any unwitnessed falls where staff cannot confirm the resident has not hit their head.||PA Low||Reporting Complete||22/02/2017|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||There was no documented evidence that meeting minutes included discussion around quality data trends analysis and what actions were required by staff. There was no evidence of internal audit outcomes being discussed at staff meetings.||Ensure that staff meeting minutes include discussion of quality data trends analysis and actions required, if any. Ensure that internal audit outcomes are discussed at staff meetings.||PA Low||Reporting Complete||22/02/2017|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i)There were no wound assessments for one resident with an open wound of the toes and one resident with a stage I pressure injury of heels. The change of dressing for one other wound had not been documented as completed as per the documented frequency, (ii) There were no documented interventions for one dementia care resident for a) changes to mobility and b) risks associated with the use of a restraint (lap belt). The same resident did not have recent episodes of challenging behaviour docum… (this text has been trimmed due to space limits).||(i)Ensure wound assessments and evaluations are completed; (ii)- (iii) Ensure interventions are documented to meet the resident’s current health status. (iv) Ensure pain relief is evaluated||PA Moderate||Reporting Complete||08/06/2017|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||A complaint was received September 2016. There was no documented evidence of corrective actions and resolution for the complaint. There was no documented complaint register in place.||Ensure that there is a documented complaint register in place. Ensure complaints include documented follow up and resolution.||PA Low||Reporting Complete||14/07/2017|
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: 22 November 2016
Audit type:Surveillance Audit
- Springvale Manor Rest Home - Nov 2016 (docx, 32.94 KB)
- Springvale Manor Rest Home - Nov 2016 (pdf, 130.73 KB)
Audit type:Certification Audit
- Springvale Manor Rest Home - Jul 2015 (docx, 44.55 KB)
- Springvale Manor Rest Home - Jul 2015 (pdf, 173.98 KB)
Audit type:Surveillance Audit
- Springvale Manor Rest Home - Jul 2014 (docx, 81.68 KB)
- Springvale Manor Rest Home - Jul 2014 (pdf, 524.1 KB)
Audit type:Partial Provisional Audit
- Springvale Manor Rest Home - Jan 2014 (docx, 68.05 KB)
- Springvale Manor Rest Home - Jan 2014 (pdf, 495.82 KB)
Audit type:Certification Audit
Audit type:Surveillance Audit