Premise details
- Address
- Single floor. 47 Treadwell Street Springvale Whanganui 4501
- Total beds
- 27
- Service types
- Dementia care, Rest home care
Certification/licence details
- Certification/licence name
- Living Waters Medical Solutions Limited - Springvale Manor
- 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 |
|---|---|---|---|---|---|
| A medication management system shall be implemented appropriate to the scope of the service. | i). Two residents discontinued medications had not been returned to the pharmacy. ii). Medication (Lactulose) prescribed for one resident was used for several residents. iii). Following the use of PRN medications (including antipsychotic medications), there is no documented follow-up the next day (or earliest opportunity) by the registered nurse for efficacy. iv). There was no consistent evidence of a GP three monthly review. | i). Ensure medications are returned to the pharmacy when no longer required. ii). Ensure medication is only used for the person it is prescribed for. iii). Ensure that any PRN medications given are reviewed for efficacy. iv). Ensure there is evidence of routine three monthly reviews by the GP. | PA Moderate | Reporting Complete | |
| My advance directives (written or oral) shall be followed wherever possible. | In three of the five files reviewed, the resuscitation status forms were incorrectly completed. In these cases, the GP completed the wrong section of the form by deeming the resident competent, despite them residing in the dementia unit, and the advance directive was signed by a family member. | Ensure that advanced directives around resident’s resuscitation status completed correctly. | PA Low | Reporting Complete | |
| The physical environment, internal and external, shall be safe and accessible, minimise risk of harm, and promote safe mobility and independence. | The carpet in the main lounge is worn and threadbare in places creating trip hazards for the residents. | Ensure the carpet in the lounge area is either replaced or repaired. | PA Moderate | Reporting Complete | |
| The frequency and extent of monitoring of people during restraint shall be determined by a registered health professional and implemented according to this determination. | Two-hourly monitoring by healthcare assistants was evident; however, the time of restraint initiation and release was not documented. Although monitoring was signed off, the absence of recorded times means the duration of restraint could not be determined. | Ensure that the time of restraint initiation and release is clearly documented. | PA Low | Reporting Complete | |
| Service providers shall conduct comprehensive reviews at least six-monthly of all restraint practices used by the service, including: (a) That a human rights-based approach underpins the review process; (b) The extent of restraint, the types of restraint being used, and any trends; (c) Mitigating and managing the risk to people and health care and support workers; (d) Progress towards eliminating restraint and development of alternatives to using restraint; (e) Adverse outcomes; (f) Compliance w | i). The care plan of the resident using restraint showed that it was dated July 2023. There was evidence that the family had last signed a restraint consent form in April 2024. ii). There was no evidence of meetings held to review restraint practice. | i). Ensure whānau are involved at least six monthly in the review of restraint. ii). Ensure review meetings are held at least six monthly and evidence a review of all restraint practices | PA Low | Reporting Complete | |
| My complaint shall be addressed and resolved in accordance with the Code of Health and Disability Services Consumers’ Rights. | i). Complaint register did not include supporting documents such as complaint acknowledgement letters, investigations, meetings and outcome letters and appeal process and resolution. ii). The HDC complaint did not have any documents from the complaint letter to the latest documentation that was provided to the HDC. | i). & ii). Ensure that complaints process is followed in accordance with guidelines set by the Health and Disability Commissioner. | PA Low | Reporting Complete | |
| Governance bodies shall ensure service providers’ structure, purpose, values, scope, direction, performance, and goals are clearly identified, monitored, reviewed, and evaluated at defined intervals. | While a 2024 business plan is in place, the owner is in the process of updating it to reflect future strategic direction. | Ensure the business plan is up to date. | PA Low | Reporting Complete | |
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | The internal audit completed around resident files and documentation was not accurately completed to reflect actual practice. | Ensure that audits undertaken accurately reflect actual practice. | PA Low | Reporting Complete | |
| Planned review of a person’s care or support plan shall: (a) Be undertaken at defined intervals in collaboration with the person and whānau, together with wider service providers; (b) Include the use of a range of outcome measurements; (c) Record the degree of achievement against the person’s agreed goals and aspiration as well as whānau goals and aspirations; (d) Identify changes to the person’s care or support plan, which are agreed collaboratively through the ongoing re-assessment and review | i). Eighteen short-term care plans were not signed off or transferred to the long-term plan. ii). Two residents treated for infections did not have a short-term plan as per policy. iii). One interRAI reviewed showed that the falls the resident had had in the last month was one fall when incident forms identify four falls. | i). Ensure short-term care plans are signed off or are transferred to the long-term plan if not resolved in three weeks. ii). Ensure short-term care plans are developed for any acute changes in condition. iii). Ensure data used to inform the interRAI is accurate. | PA Moderate | Reporting Complete | |
| Service providers shall maintain quality records that comply with the relevant legislation, health information standards, and professional guidelines, including in terms of privacy. | i). Resident clinical records were not consistently up to date, and several documents, including assessments and care plans, were found to be unsigned and undated. ii). Staff members used their personal mobile phone to request PRN medication from the clinical manager, contrary to information privacy and security protocols. | i). Ensure that all records are signed and dated. ii). The service will implement measures to ensure staff do not use personal devices for clinical communication, thereby upholding resident privacy and confidentiality. | PA Moderate | Reporting Complete | |
| An approved food control plan shall be available as required. | i). Fridge temperatures are only recorded Monday to Friday. ii). There was no records found of the freezer temperatures being recorded. iii). Food that had been decanted from its original containers were not all dated of opening or expiry date. | i). & ii). Ensure fridge and freezer temperatures are recorded daily. iii). Ensure any decanted food is dated on opening and has the expiry date recorded. | PA Low | Reporting Complete | |
| Surveillance activities shall be appropriate for the service provider and take into account the following: (a) Size and complexity of the service; (b) Type of services provided; (c) Acuity, risk factors, and needs of the people receiving services; (d) Health and safety risk to, and of, the workforce; (e) Systemic risk to the health and disability system as a whole. | While antimicrobial use was monitored as part of infection surveillance, there was no documentation of treatment effectiveness, limiting the ability to evaluate whether antimicrobial interventions were appropriate or successful. | Ensure that effectiveness of antimicrobial usage is documented. | PA Low | 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 | i). There was no evidence of a pain assessment completed for a rest home resident experiencing pain. ii). One resident in the dementia resident had no interventions documented in a care plan who had been in the facility for 18 months. iii). There is no consistent evidence of RN general weekly review of residents in progress notes for all five files reviewed. iv). There was no consistent evidence of progress notes documented by HCAs each shift as per policy for one rest home resident. v). In ca | i). Ensure pain assessments are documented as per policy. ii). Ensure all residents have a care plan documented. iii).- v). Ensure progress notes are documented by the HCAs and RNs as per policy. vi). & vii). Ensure care plan interventions are reflective of residents current needs. | PA Moderate | Reporting Complete | |
| The nutritional value of menus shall be reviewed by appropriately qualified personnel such as dietitians. | There was no documented evidence of a review of the menu by a dietitian. | Ensure that the menu is review by a qualified dietitian | PA Low | Reporting Complete | |
| 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 had been in the home at dementia level care for eighteen months and did not have a long-term care plan in place. ii). One file in the dementia unit evidenced the initial care plan was not completed within the required timeframe of 24 hours. iii). Evidence of family/whānau involvement in care planning was not evidenced in all five resident files reviewed. iv). All five files could not provide evidence of a review by the general practitioner within five days of admission. v). | i). & ii). Ensure care plans are completed in the required timeframes. iii). Ensure resident and family/whānau involvement in care planning is documented. iv). Ensure all residents are reviewed by the GP within five days of admission. v). Ensure all initial interRAI assessments are completed within 21 days of admission. | PA Moderate | Reporting Complete | |
| Alternative essential energy and utility sources shall be available, in the event of the main supplies failing. | There is no alternative energy source in the event of main power failing. | Ensure that the facility has access to a generator in the event of a mains power failure. | 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 corrective action manager.
- Date action reported complete
The date that the corrective action manager 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: Provisional Audit
