Waihi Lodge Care Centre

Profile & contact details

Premises details
Premises name	Waihi Lodge Care Centre
Address	16 Shaw Street Geraldine 7930
Total beds	21
Service types	Rest home care

Certification/licence details
Certification/licence name	Seniorcare Geraldine Incorporated - Waihi Lodge Care Centre
Current auditor	Health and Disability Auditing New Zealand Limited
End date of current certificate/licence	29 June 2024
Certification period	24 months

Provider details
Provider name	Seniorcare Geraldine Incorporated
Street address	16 Shaw Street Geraldine 7930
Post address

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 April 2023

Outcome required	Found at audit	Action required	Risk rating	Action status	Date action reported complete
Service providers shall ensure the quality and risk management system has executive commitment and demonstrates participation by the workforce and people using the service.	i). Staff meeting minutes do not reflect discussion of quality data, including infection control, adverse events, internal audit results, or corrective actions. ii). Meeting minutes do not reflect discussion around quality goals or related progress.	i).& ii). Ensure meeting minutes reflect discussion on quality data and progress towards meeting quality goals.	PA Low	Reporting Complete	01/11/2023
Results of surveillance and recommendations to improve performance where necessary shall be identified, documented, and reported back to the governance body and shared with relevant people in a timely manner.	Ensure infective organisms are identified.	Ensure infective organisms are identified and documented.	PA Low	Reporting Complete	01/11/2022
Service providers shall have a clearly defined and documented IP programme that shall be: (a) Developed by those with IP expertise; (b) Approved by the governance body; (c) Linked to the quality improvement programme; and (d) Reviewed and reported on annually.	The annual infection data for 2021 has not been reviewed or reported.	Ensure the annual infection review is completed for 2021.	PA Low	Reporting Complete	01/11/2022
Health care and support workers shall receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.	Fire evacuation drills have not been conducted six monthly as required – last held in September 2020.	Provide evidence that fire evacuation drills are conducted six monthly as per requirements.	PA Moderate	Reporting Complete	01/11/2022
Buildings, plant, and equipment shall be fit for purpose, and comply with legislation relevant to the health and disability service being provided. The environment is inclusive of peoples’ cultures and supports cultural practices.	Not all test and tag of electrical equipment can be evidenced as occurring annually.	Ensure test and tag of electrical items is completed annually.	PA Low	Reporting Complete	01/11/2022
Service providers shall facilitate safe self-administration of medication where appropriate.	i) Three residents who self-administer medications did not evidence three monthly competencies as per policy. ii) The medications of three residents who self-administer medication were not stored securely, with one medication visible on a bedside locker.	i) Ensure self-medicating residents’ evidence three monthly competencies as per policy. ii) Ensure self-medicating residents can securely store their medications in their room.	PA Moderate	Reporting Complete	01/11/2022
A medication management system shall be implemented appropriate to the scope of the service.	i) Six monthly pharmacy stocktakes have not been completed. ii) Medication fridge temperatures are not monitored. iii) Medications are stored in an area accessible to all staff including non-clinical staff. iv) There is no documented agreement with the pharmacy.	i) Ensure a six-monthly controlled stocktake is completed as per policy. ii) Ensure medication fridge temperatures are monitored as per policy. iii) Provide a safe area for medication storage which is only accessible to authorised staff. iv) Ensure there is a documented agreement with the pharmacy supplying medications to the facility.	PA Moderate	Reporting Complete	01/11/2022
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.	Two of five resident files reviewed did not include a lifestyle profile and activities assessment.	Ensure all residents have a lifestyle profile and assessment documented.	PA Low	Reporting Complete	01/11/2022
Service providers shall engage with people receiving services to assess and develop their individual care or support plan in a timely manner. Whānau shall be involved when the person receiving services requests this.	i) A long-term care plan has not been documented for a permanent resident admitted as a permanent resident five weeks ago. ii) Care plan evaluations and activity plan evaluations have not occurred within required timeframes for three of four files reviewed (one was not required). iii) Dietary profiles and nutritional assessments have not been updated within required timeframes.	i) Ensure that long term care plans are documented within 21 days of admission. ii) Ensure care plan evaluations occur at least six monthly. iii) Ensure dietary profiles evidence review as per policy.	PA Low	Reporting Complete	01/11/2022
Health care and support workers shall have the opportunity to discuss and review performance at defined intervals.	Four of six staff files reviewed did not evidence that annual appraisals had been conducted.	Ensure that all staff have an annual appraisal conducted as per contractual requirements.	PA Low	Reporting Complete	01/11/2022
Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided.	Two of six staff files reviewed did not evidence completed orientation documentation.	Ensure that all new staff complete an orientation process, and that orientation documentation is signed off as completed.	PA Low	Reporting Complete	01/11/2022
Service providers shall ensure there is a system to identify, plan, facilitate, and record ongoing learning and development for health care and support workers so that they can provide high-quality safe services.	The education programme for the past two years has not been fully implemented.	Provide evidence that education and training is being conducted for all staff as per education and training plan.	PA Low	Reporting Complete	01/11/2022
Service providers shall evaluate progress against quality outcomes.	Internal audits have not been fully completed over 2020 and 2021; and ii) resident meetings have not been held since April 2021.	Ensure that internal audits are completed as per the audit schedule; and ii) provide evidence that resident meetings are held and minuted.	PA Low	Reporting Complete	01/11/2022
A medication management system shall be implemented appropriate to the scope of the service.	Six-monthly controlled drug stocktakes have not been completed.	Ensure six-monthly controlled drug stocktakes are completed.	PA Moderate	Reporting Complete	01/11/2023

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 April 2023

Audit type:Surveillance Audit

Audit date: 08 April 2022

Audit type:Certification Audit

Audit date: 12 April 2018

Audit type:Certification Audit

Audit date: 11 October 2016

Audit type:Surveillance Audit

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