Premise details
- Address
- 5 Diggers Gully Road Kurow 9435
- Total beds
- 14
- Service types
- Rest home care
Certification/licence details
- Certification/licence name
- The Whalan Lodge Trust - Whalan Lodge
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- The Whalan Lodge Trust
- Street address
- 5 Diggers Gulley Road Kurow 9435
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 |
|---|---|---|---|---|---|
| Governance bodies shall have demonstrated expertise in Te Tiriti, health equity, and cultural safety as core competencies. | There is no evidence of the Trust completing cultural training to include Te Tiriti o Waitangi, health equity and cultural safety. | Ensure Trust members complete cultural training. | PA Low | In Progress | |
| There shall be a clinical governance structure in place that is appropriate to the size and complexity of the service provision. | A clinical governance structure is not in place. | Ensure the development of a clinical governance structure appropriate to the size and complexity of Whalan Lodge. | PA Low | In Progress | |
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | (i). Six of the internal audits had not been completed as per the schedule. (ii). The information collected by internal audits and the corrective actions are not discussed in meetings to ensure any outstanding matters are addressed with sign-off when completed. (iii). The results of the 2023 satisfaction survey has not been evidenced as being shared with the staff, residents, family/whānau. (iv). The hazard register could not be located; therefore, the annual review could not be verified. (v). | (i). Ensure the internal audit schedule is completed. (ii). Ensure the results of audits and complaints are evidenced as being discussed at staff meetings and included in the minutes of meetings. (iii). Ensure survey results are collated and available to staff, residents and family/whānau. (iv). Ensure there is evidence of the hazard register annual review and is readily accessible to staff. (v). Ensure the manager’s report includes quality and health and safety data. | PA Low | 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. | The CPU is yet to be signed off and issued. | Ensure the CPU is in place prior to occupancy. | PA Low | In Progress | |
| My service provider shall work in partnership with iwi and Māori organisations within and beyond the health sector to allow for better service integration, planning, and support for Māori. | There is no evidence the Trust has a relationship iwi and Māori organisations to ensure there is service integration, planning, and support for Māori. | Ensure there is a relationship between the Trust and iwi/mana whenua and Māori organisations to provide service integration, planning, and support for Māori. | PA Low | In Progress | |
| The physical environment, internal and external, shall be safe and accessible, minimise risk of harm, and promote safe mobility and independence. | (i). The five new bedrooms are yet to have the required furniture installed. (ii). The nurses’ office has not yet been fitted out as required, this includes finishing painting, safe flooring and adequate lighting. (iii). Dispensers for flowing soap, handtowels and hand sanitiser (bedroom, communal bathroom, hallways) are yet to be installed. (iv). New areas are being developed for outdoor access are not yet landscaped. (v). Seating and shaded areas and appropriate handrails are yet to be instal | (i). Ensure furniture is installed in the new bedrooms. (ii). Ensure the nurses’ office is fully fitted and functional. (iii). Ensure all hand soap dispensers and hand sanitisers are installed. (iv).- (v). Ensure all outdoor areas are safe for residents to use with seating and shade provided. (vi). Ensure the dining area is completed. | PA Low | In Progress | |
| Governance bodies shall evidence leadership and commitment to the quality and risk management system. | The business plan does not provide evidence of the Trust’s sign off of the Whalan Lodge quality and risk management system, including restraint management, infection prevention control and management, antimicrobial stewardship, or reference the Māori and Pasifika health plans. | Ensure there is evidence of the Trust’s sign off of the Whalan Lodge quality and risk management system, to include restraint management, infection prevention control and management, antimicrobial stewardship, and the Māori and Pasifika health plans. | PA Low | In Progress | |
| Where required by legislation, there shall be a Fire and Emergency New Zealand- approved evacuation plan. | The fire evacuation scheme is in the process of being updated with a fire drill arranged prior to occupancy. | Ensure the fire evacuation scheme is updated, with a fire drill completed. | PA Low | In Progress | |
| My service provider shall work in partnership with Pacific communities and organisations, within and beyond the health and disability sector, to enable better planning, support, interventions, research, and evaluation of the health and wellbeing of Pacific peoples to improve outcomes. | Whalan Lodge Trust has not yet partnered with their Pacific communities or local healthcare providers to ensure connectivity within the region to increase knowledge, awareness and understanding of the needs of Pacific people. | Ensure the Trust develops a partnership with the Pasifika community or Pasifika healthcare provider. | PA Low | 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. | At present there is no generator outlet; however, when one is installed, staff will need to be trained in the use of the outlet and there will be a procedure put in place with staff training. | Ensure when the generator outlet is installed, the staff are trained and a procedure put in place. | PA Low | In Progress | |
| Service providers shall have a documented AMS programme that sets out to optimise antimicrobial use and minimising harm. This shall be: (a) Appropriate for the size, scope, and complexity of the service; (b) Approved by the governance body; (c) Developed using evidence-based antimicrobial prescribing guidance and expertise (which includes restrictions and approval processes where necessary and access to laboratory diagnostic testing reports). | Compliance on antibiotic and antimicrobial use is not currently collated, evaluated or analysed. | Ensure compliance on antibiotic and antimicrobial use is collated, evaluated or analysed. | PA Low | In Progress | |
| Service providers shall understand and comply with statutory and regulatory obligations in relation to essential notification reporting. | There was no evidence of a Section 31 notification completed to notify HealthCERT of the change in manager. | Ensure completion of Section 31 notifications as required. | PA Low | In Progress | |
| An appropriate call system shall be available to summon assistance when required. | Partial provisional: (i). The service is installing a new call bell system and screens which is not yet fully operational. (ii). A call bell internal audit is yet to be completed. (iii). Training is yet to be provided to staff around the new call bell system. | (i). Ensure the call bell system is fully operational prior to occupancy. (ii). Ensure internal call bell audits are completed according to schedule once the new system is operational. (ii). Ensure training is provided to staff around the new call bell system. | PA Low | In Progress | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | Three files that required a performance appraisal had no evidence of a completed performance appraisal on file. | Ensure appraisals are completed as per the schedule. | PA Low | In Progress | |
| Service providers, shall evaluate the effectiveness of their AMS programme by: (a) Monitoring the quality and quantity of antimicrobial prescribing, dispensing, and administration and occurrence of adverse effects; (b) Identifying areas for improvement and evaluating the progress of AMS activities. | The service does not currently monitor or analyse antimicrobial use. | Ensure antimicrobial use is monitored and analysed. | PA Low | In Progress | |
| Service providers shall improve health equity through critical analysis of organisational practices. | Ethnicity data is not collated with quality data to provide a critical analysis of organisational practices. | Ensure ethnicity data is included in quality data to provide a critical analysis of organisational practices. | PA Low | In Progress | |
| My complaint shall be addressed and resolved in accordance with the Code of Health and Disability Services Consumers’ Rights. | (i). There was no evidence of a complaint process being followed for a complaint made in 2023. (ii). The complaint was not evidenced as being discussed at staff meetings as per policy. | (i). Ensure the complaints policy is followed. (ii). Ensure discussions held with staff in relation to complaints is documented. | PA Low | In Progress | |
| Governance bodies shall have meaningful Māori representation on relevant organisational boards, and these representatives shall have substantive input into organisational operational policies. | The Trust does not have formal collaboration with mana whenua or local Māori Health providers in business planning and service development. | Ensure there is evidence of Māori representation at Trust level. | PA Low | In Progress | |
| Service providers shall ensure there are safe and effective laundry services appropriate to the size and scope of the health and disability service that include: (a) Methods, frequency, and materials used for laundry processes; (b) Laundry processes being monitored for effectiveness; (c) A clear separation between handling and storage of clean and dirty laundry; (d) Access to designated areas for the safe and hygienic storage of laundry equipment and chemicals. This shall be reflected in a writt | (i). The new laundry area is not yet functional. (ii). The sanitiser is yet to be installed and functional. (iii). Policies, procedures are not yet updated to reflect the changes and training will be required in relation to new equipment. | (i).-(ii). Ensure the new laundry area is fully fitted and equipment is operational. (iii). Ensure policies and procedures are updated and staff training is held. | 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; Partial Provisional Audit
Audit date:
Audit type: Surveillance Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Surveillance Audit
Audit date:
Audit type: Certification Audit
