Premise details
- Address
- 24 Innes Street Waimate 7924
- Total beds
- 63
- Service types
- Rest home care, Geriatric, Medical
Certification/licence details
- Certification/licence name
- Lister Home Incorporated - Lister Home
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 24 months
Provider details
- Provider name
- Lister Home Incorporated
- Street address
- 24 Innes Street Waimate 7924
- Postal address
- PO Box 25 Waimate 7960
Progress on issues from the last audit
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.
| Outcome required | Found at audit | Action required | Risk rating | Action status | Date action reported complete |
|---|---|---|---|---|---|
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | i). There was no documented evidence in the staff meeting minutes of quality data collated (KPIs), internal audits or corrective actions, complaints, or satisfaction survey results. ii). There was no evidence of analysis of data around infection control and incident reports being available to staff who have not attended meetings. iii). There were two resident meetings held in 2022 and one resident meeting held in 2023. iv). Satisfaction survey results have not been analysed and shared with re | i). & ii). Ensure meeting minutes are reflective of the discussions held around quality data and information is available for staff who were unable to attend the meeting. iii). Ensure residents meetings are held on a regular basis. iv). Ensure satisfaction survey results are collated, analysed and results are shared with residents, family/whānau and staff. | PA Moderate | In Progress | |
| 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. | Medical equipment including thermometer’s and sphygmomanometer have not been calibrated since 2021. | Ensure all medical equipment is calibrated as per policy and legislation | PA Low | In Progress | |
| 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. | Timeframes related to contractual requirements were not always completed for the files reviewed including: i). Two of six initial interRAI assessments (one hospital and one rest home) were not completed within three weeks of admission. ii).Two residents (one hospital and one rest home) did not have an initial long-term care plan completed within three weeks of admission. iii). One repeat interRAI assessment for a hospital resident had not been completed in required timeframes. iv). Six monthly c | i-iv). Ensure assessments, care planning and evaluations occur within contractual timeframes. i). Ensure short term care plans are transferred to the long-term care plan after six weeks | PA Moderate | In Progress | |
| Service providers shall identify external and internal risks and opportunities, including potential inequities, and develop a plan to respond to them. | The electronic incident reports reviewed for December 2023 and January 2024 were not fully completed did not evidence ongoing RN follow up or opportunities to minimise future risks. | Ensure incident reports are fully completed to evidence RN follow up post falls and opportunity to minimise future risks. | PA Low | In Progress | |
| A medication management system shall be implemented appropriate to the scope of the service. | i). Room temperatures in the hospital wing evidenced four recent occasions where the temperature was above 25 degrees. ii). A six-monthly physical check and reconciliation of controlled drugs has not been implemented for over 14 months. iii) Weekly controlled drug medication’s checks have not always occurred weekly as scheduled. | i). Ensure medication room temperatures are maintained below 25 degrees. ii). Ensure six-monthly physical checks and reconciliation of controlled drugs is completed six-monthly. iii). Ensure weekly controlled drug checks are implemented as scheduled. | PA Moderate | In 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 | i).Two hospital residents with aggressive behaviours has no interventions documented to manage associated risks. ii). Two residents (one hospital and one rest home) residents assessed as a moderate or high falls risk did not have interventions documented to manage the risk. iii). One rest home resident with a stoma did not have care interventions documented to manage stoma care. iv). One hospital resident with frequent urinary tract infections did not have risks or interventions documented in th | i). - vii) Ensure all care plan interventions are current, individualised and reflect the assessed needs of residents. | PA Moderate | In Progress | |
| 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 | i). Restraint monitoring had not been completed as scheduled for two of two residents using restraint. ii). Repositioning charts were not completed as scheduled for two of two resident files reviewed. | i-ii). Ensure monitoring occurs as per monitoring requirements. | PA Moderate | In Progress | |
| Menu development that considers food preferences, dietary needs, intolerances, allergies, and cultural preferences shall be undertaken in consultation with people receiving services. | Resident dietary profiles evidenced files which had not been reviewed for over two years. | Ensure dietary profiles are reviewed as per policy | PA Moderate | In Progress | |
| Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided. | Six of 10 staff files reviewed did not evidence completed orientation documentation. | Ensure all staff orientation documentation is held on staff files. | PA Low | In Progress | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | Six files out of 10 did not evidence annual appraisals. | Ensure all staff complete annual appraisals. | PA Low | In Progress | |
| Surveillance methods, tools, documentation, analysis, and assignment of responsibilities shall be described and documented using standardised surveillance definitions. Surveillance includes ethnicity data. | i). There was no documented evidence or log of outbreaks outlining the length of the outbreak, residents and staff affected. ii). There was no consistent evidence of debrief meeting held with staff to discuss successes and improvements. | i). Ensure infection logs are maintained for all infectious outbreaks. ii). Ensure there is documented evidence of debrief meetings held with staff. | PA Low | In Progress | |
| All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal shall comply with current legislation and guidelines. | Dry ingredients had been decanted into containers which did not evidence expiry dates. | Ensure all food decanted into containers has the expiry date documented on the container | PA Moderate | In Progress |
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
About audit reports
Audit reports for this rest home’s latest audits can be downloaded below.
Before you begin
Before you download the audit reports, please read our guide to rest home certification and audits. The guide gives an overview of the auditing process and explains what the audit reports mean.
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.
Before 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) appear on the rest home’s page. As the rest home completes the required actions, the status on the website updates.
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Surveillance Audit
Audit date:
Audit type: Partial Provisional Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Surveillance Audit
Audit date:
Audit type: Certification Audit
