Premise details
- Address
- 95 Cole Street Masterton 5810
- Total beds
- 23
- Service types
- Dementia care
Certification/licence details
- Certification/licence name
- Lyndale Care Limited - Lyndale Villa and Manor
- Current auditor
- The DAA Group Limited
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- Lyndale Care Limited
- Street address
- Lyndale Villa and Lyndale Manor 52 Cole Street Masterton 5810
- Postal address
- 52 Cole Street Masterton 5810
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 |
|---|---|---|---|---|---|
| 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 | Cultural and lifestyle assessments have not been completed for residents residing in the secure dementia unit and neurological observations are not being completed for residents who have had an unwitnessed fall. | Provide evidence the required cultural and lifestyle assessments are completed for residents in the secure dementia unit and that neurological assessments are being completed for all residents’ who have had an unwitnessed fall. | PA Moderate | Reporting Complete | |
| The nutritional value of menus shall be reviewed by appropriately qualified personnel such as dietitians. | The present menu is currently being reviewed by a dietician; however, the menu at this time has not been reviewed since July 2021. | Provide evidence the menu has been reviewed by the dietician. | PA Low | Reporting Complete | |
| 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 | The documentation of care requirements in the care plans of residents in the Manor were not always consistent with meeting the residents’ assessed needs. | Provide evidence the documentation in the care plan of residents in the Manor is consistent with meeting the residents’ assessed needs. | PA Moderate | Reporting Complete | |
| 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. | Meaningful activities that focussed on resident’s previous lifestyle patterns and enhanced residents’ strengths, skills, and interests were not offered in the secure dementia unit. | Provide evidence meaningful activities are provided in the secure dementia unit that enhance residents’ strengths, skills, and interests. Provide evidence that the programme is overseen or implemented by a person skilled in assessment, implementation, and evaluation of diversional and motivational recreation. | PA Moderate | Reporting Complete | |
| 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 | There was no evidence to verify the ICO had completed continuing education on IPC and AMS. | Provide evidence the ICO has completed continuing education in IPC and AMS. | PA Low | Reporting Complete | |
| Governance bodies shall have meaningful Māori representation on relevant organisational boards, and these representatives shall have substantive input into organisational operational policies. | Lyndale has no formal alliances with Māori to support meaningful input into organisational policy and plans for Māori in the service. | Provide evidence that formal alliances with Māori to support meaningful input into organisational policy and plans for Māori in the service have been established. | PA Low | Reporting Complete | |
| Service providers shall evaluate progress against quality outcomes. | Internal audits and incident reporting processes are not being completed to evaluate progress against quality outcomes. | Provide evidence that internal audits and incident reporting processes are being completed to evaluate progress and improve quality outcomes. | PA Moderate | Reporting Complete | |
| 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 | Cultural and lifestyle assessments have not been completed for residents residing in the secure dementia unit and neurological observations are not being completed for residents who have had an unwitnessed fall. | Provide evidence the required cultural and lifestyle assessments are completed for residents in the secure dementia unit and that neurological assessments are being completed for all residents’ who have had an unwitnessed fall. | PA Moderate | Reporting Complete | |
| The nutritional value of menus shall be reviewed by appropriately qualified personnel such as dietitians. | The present menu is currently being reviewed by a dietician; however, the menu at this time has not been reviewed since July 2021. | Provide evidence the menu has been reviewed by the dietician. | PA Low | Reporting Complete | |
| 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 | The documentation of care requirements in the care plans of residents in the Manor were not always consistent with meeting the residents’ assessed needs. | Provide evidence the documentation in the care plan of residents in the Manor is consistent with meeting the residents’ assessed needs. | PA Moderate | Reporting Complete | |
| 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. | Meaningful activities that focussed on resident’s previous lifestyle patterns and enhanced residents’ strengths, skills, and interests were not offered in the secure dementia unit. | Provide evidence meaningful activities are provided in the secure dementia unit that enhance residents’ strengths, skills, and interests. Provide evidence that the programme is overseen or implemented by a person skilled in assessment, implementation, and evaluation of diversional and motivational recreation. | PA Moderate | Reporting Complete | |
| 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 | There was no evidence to verify the ICO had completed continuing education on IPC and AMS. | Provide evidence the ICO has completed continuing education in IPC and AMS. | PA Low | Reporting Complete | |
| Governance bodies shall have meaningful Māori representation on relevant organisational boards, and these representatives shall have substantive input into organisational operational policies. | Lyndale has no formal alliances with Māori to support meaningful input into organisational policy and plans for Māori in the service. | Provide evidence that formal alliances with Māori to support meaningful input into organisational policy and plans for Māori in the service have been established. | PA Low | Reporting Complete | |
| Service providers shall evaluate progress against quality outcomes. | Internal audits and incident reporting processes are not being completed to evaluate progress against quality outcomes. | Provide evidence that internal audits and incident reporting processes are being completed to evaluate progress and improve quality outcomes. | PA Moderate | Reporting Complete |
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: Certification Audit
Audit date:
Audit type: Surveillance Audit
Audit date:
Audit type: Partial Provisional Audit; Surveillance Audit
