Premise details
- Address
- Ground floor 136 Great North Road Otamatea Whanganui 4500
- Website
- https://www.eldernet.co.nz/Facilities/Rest_Home_Care/Virginia_Lodge/Service/DisplayService/FaStID/11451
- Total beds
- 21
- Service types
- Rest home care
Certification/licence details
- Certification/licence name
- Living Waters Medical Solutions Limited - Living Waters Rest Home
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 24 months
Provider details
- Provider name
- Living Waters Medical Solutions Limited
- Street address
- 5 Rakau Road Castlecliff Whanganui 4501
- Postal address
- 5 Rakau Road Castlecliff Whanganui 4501
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). Staff/quality and registered nurse meetings have not been completed as scheduled since last audit. (ii). Internal audits have not been completed as scheduled. (iii). Resident and family/whanau satisfaction surveys have not been completed since last audit. | (i)-(iii)Ensure meetings, audits and satisfaction surveys are completed as scheduled. | PA Moderate | In Progress | |
| There shall be a clinical governance structure in place that is appropriate to the size and complexity of the service provision. | There is no clinical governance structure in place to meet the requirements of the service | Ensure that there is a clinical governance structure in place to meet the requirements of the service. | PA Moderate | In Progress | |
| Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services. | (i). Review of the roster does not evidence a true reflection of the days and hours that the clinical nurse manager is working at Living Waters Rest Home. (ii). The clinical and day to day operational oversight is not providing assurance for the required provision of culturally and clinically safe service. | (i). Ensure the roster provides an accurate reflection of the hours and days to be worked by staff. (ii). Ensure there is adequate clinical and day to day oversight to provide culturally and clinically safe service. | 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. | i). One resident’s initial care plan does not reflect the referral support plan provided by mental health services. ii). One resident, admitted 2024, with complex needs has no long-term care plan documented, two further resident files in an extended sample (admitted November and early December respectively) also do not have a long-term care plan. iii). One resident’s initial care plan is not dated. | i). Ensure initial care plans reflect the referral information so that the plan reflect the resident’s needs. ii). Ensure long term care plans are completed within timeframes. iii). Ensure all documentation is dated. | PA Moderate | In Progress | |
| Governance bodies shall appoint a suitably qualified or experienced person to manage the service provider with authority, accountability, and responsibility for service provision. | The current organisational structure does not provide assurance that there is the required organisational governance, management and clinical support needed to ensure safe and effective delivery of required service. | Ensure that the organisational structure is set in a way that provides safe and effective delivery of required service. | PA Moderate | In 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. | There is no activity plan documented for the current or ongoing months. | Ensure that there are planned activities, and this is communicated to residents. | PA Low | In Progress | |
| Governance bodies shall evidence leadership and commitment to the quality and risk management system. | At the time of the audit there was no documented evidence of the managing director review and involvement in quality and risk management system and processes of Living Waters Rest Home. | Ensure that there is evidence of managing director involvement in quality and risk management systems and processes. | 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. | (i). There is no evidence of discussion of quality data and improvement with staff including (but not limited to) that related to incidents, infections, surveys, complaints / compliments, restraint, training, internal audits and outcomes. (ii). The business plan goals have not been evidenced as being reviewed. | (i). Ensure evidence of quality data being discussed with staff is available. (ii). Ensure the goals in the business plan are reviewed regularly. | PA Moderate | In 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 | The infection control coordinator has not completed external education on infection prevention and control for clinical staff. | Ensure that the infection control coordinator completes education required. | PA Low | 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). One resident had no care plan interventions or other documentation in place to fully reflect their changed medical needs on return from hospital. ii). One resident file documents mobility aids are needed but does not state what they are and when to use them, this same file documents the risk of seizures, and recognition but not the interventions. iii). Residents’ primary medical treatment is being completed by a nurse prescriber and not a general practitioner / nurse practitioner as per ARRC | i). Ensure short term care plans / long term care plans are updated to reflect acute changes to care needs. ii). Ensure that care plan reflect the resident’s need and provides guidance to staff. iii). Residents’ primary medical treatment must be completed by a general practitioner / nurse practitioner as per ARRC agreement D16.5E. iv). Ensure the wound care policies, procedure and documentation documented. | PA Moderate | In Progress | |
| 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. | There was no evidence of a fire drill being conducted since May 2024 | Ensure fire drills are undertaken six monthly | PA Low | In Progress | |
| 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 infection control programme has not been reviewed annually as scheduled. | Ensure the infection control programme is reviewed as scheduled. | PA Low | 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). Three separate falls identified through incident forms do not document follow up by the RN on the incident form or through progress notes. ii). Neurological observations have not been recorded according to policy for these three falls. iii). One resident with stated suicidal ideology had 15-minute observations documented; however, there is no documented RN review or STCP in place. A referral to mental health services has been documented and since the episode the resident has been reviewed; | i). Ensure the RN documents post fall follow up either on the incident form or progress notes. ii). Ensure neurological observations are completed according to policy. iii). Ensure the RN reviews residents and documented required interventions including resident checks. | PA Moderate | In Progress | |
| Service providers shall maintain an information management system that: (a) Ensures the captured data is collected and stored through a centralised system to reduce multiple copies or versions, inconsistencies, and duplication; (b) Makes the information manageable; (c) Ensures the information is accessible for all those who need it; (d) Complies with relevant legislation; (e) Integrates an individual’s health and support records. | (i). Residents records are not integrated. Progress notes and family/whanau communication records are documented in different files to the resident file. (ii). The service does not have access to clinical documentation from the general practitioner and the mental health services, so their input to care and support cannot be linked to the care plans and used to improve care and support for residents. (iii). Five incident forms and observation records related to events that occurred in July 2024 c | (i)-(iii). Ensure integration of a resident’s health and support records. | 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. | The clinical nurse manager has not received orientation into the role since appointment in December 2023. | Ensure there is evidence of orientation of the clinical nurse manager. | PA Low | In Progress | |
| My service provider shall practise open communication with me. | Five of six accident/incidents reviewed do not provide documented evidence of family/whānau notification, this information was not documented in the residents file either. | Ensure that family/whānau are evidenced as being notified of accident/incidents. | PA Low | In Progress | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | Three of five files (one clinical nurse manager, one healthcare assistant, one cleaner) who have been employed for over 12 months have not had a performance appraisal completed in the last 12months. | Ensure that performance appraisals are completed as scheduled. | 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. | The service had a Covid-19 outbreak in May 2024 that affected all the residents. There is no documented evidence of (i). Resident infection report forms completed. (ii). Outbreak log being completed. (iii). Notification to public health. (iv). Debrief completed with staff. (v). A report of the investigation and actions taken to prevent further communicability being completed in the monthly report by infection control coordinator as per policy. | (i)-(v). Ensure outbreak processes are implemented as per policy. | PA Low | 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: Surveillance Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Surveillance Audit
Audit date:
Audit type: Provisional Audit
