Premise details
- Address
- 30 Princess Street Waitara 4320
- Total beds
- 40
- Service types
- Dementia care, Rest home care
Certification/licence details
- Certification/licence name
- Norfolk Lodge Waitara Limited - Norfolk Lodge Rest Home
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- Norfolk Lodge Waitara Limited
- Street address
- 47 Finch Street Western Springs Auckland 1022
- Postal address
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 |
|---|---|---|---|---|---|
| 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. | (i). The resident files in the dementia unit do not include a 24-hour activity plan. (ii). There are no activities planned for the dementia unit over the weekends. | (i). Ensure the resident files in the dementia unit include a 24-hour activity plan. (ii). Ensure there are activities planned for the dementia unit over the weekends. | PA Low | In Progress | |
| Service providers shall identify external and internal risks and opportunities, including potential inequities, and develop a plan to respond to them. | The hazard register has not been evidenced as being reviewed since last audit. | Ensure the hazard register is evidenced as being reviewed annually as scheduled. | 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). An assessment process for the use of mobility aid for two non-weight bearing residents has not been documented, including one resident who is transferred using a transfer belt and two to three staff, this means that staff are not adhering to the ‘no lift policy” and one resident using a sling hoist. (ii). One file in the dementia unit does not identify behaviours are most prevalent in the evening as identified by the GP, (iii). One file in the dementia unit does not identify the resident us | (i). Ensure that there is a documented assessment to ensure that the most appropriate mobility aids and interventions are used and that care and support for residents is reflects the no lift policy”. (ii). Ensure that care plan interventions are reflective of the GP input and resident need. (iii). Ensure the care plan reflect all resident care interventions needed. (iv). – (v). Ensure the use of a hoist follows the service policy and all mobilising and positioning information is documented (vi). | 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 | Two incidents related to falls and slips where there were injuries to the face did not have evidence of neurological observations completed. | Ensure that neurological observations are completed for suspected head injury. | PA Low | In Progress | |
| Service providers shall understand and comply with statutory and regulatory obligations in relation to essential notification reporting. | (i). There is no demonstrable understanding and implementation of the adverse events report policy and process; (a). SAC categorisation is not being completed for all accident and incidents forms reviewed for the month of October 2024, and (b). SAC reporting was not completed for one resident with dementia who had a fracture neck of femur following a fall. (ii). There are no separate incident forms completed for three incidents that involved at least two individuals. (iii). There is no documen | (i). Ensure there is understanding of and implementation of the National Adverse Event Reporting Policy (ii). Ensure separate incident forms are completed for incidents that involve at least two individuals. (iii). Ensure there is documented registered nurse assessment and follow-up of incidents and actions implemented. | 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). Three of three infection report forms sighted did not have the type and site of infection documented. (ii). Two of seven infections for October 2024, five of eleven infections for December 2024 and eight of eight Covid-19 infections did not have corresponding infection reporting forms completed for each episode of infection. | (i). Ensure that the type and site of infection is documented for all infection reports. (ii). Ensure infection reporting forms are completed for all infections. | PA Low | In Progress | |
| 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. | The service had a Covid-19 outbreak in April 2024 that affected eight residents. (i). There was no documented evidence of an outbreak log being completed. (ii). There was no evidence of a debrief meeting being held with staff. (iii). A report of the investigation was not evidenced as being completed, and actions taken to prevent further communicability being completed in the monthly report by infection control coordinator. | (i).- (iii). Ensure outbreak management policy is implemented. | 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: Certification Audit
Audit date:
Audit type: Surveillance Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Surveillance Audit
