Premise details
- Address
- 5 Diggers Gully Road Kurow 9435
- Total beds
- 19
- 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 |
|---|---|---|---|---|---|
| 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 | Reporting Complete | |
| 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 | Reporting 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 | Reporting Complete | |
| 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 | Reporting Complete | |
| 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 | Reporting Complete | |
| 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 | Reporting Complete | |
| The following aspects of the system shall be performed and communicated to people by registered health professionals operating within their role and scope of practice: prescribing, dispensing, reconciliation, and review. | For those residents who have recently started a controlled drug, there was no evidence that a clinical assessment has been completed by a registered nurse to support clinical judgement; or the RN stated the resident is stable and does not require regular assessments. | Ensure the RN completes a clinical pain assessment. | PA Moderate | 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 | Reporting Complete | |
| 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 | Reporting Complete | |
| 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 | Reporting Complete | |
| 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 | Reporting Complete | |
| 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 | Reporting Complete | |
| 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 | Reporting Complete | |
| 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 | Reporting Complete | |
| 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 | Reporting Complete | |
| 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 | Reporting Complete | |
| 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 | Reporting Complete | |
| 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 | Reporting Complete | |
| 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 | Reporting Complete | |
| 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 | Reporting Complete | |
| 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. | Electrical testing of equipment has not been completed since October 2023. | Ensure electrical appliances are checked as scheduled. | 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).The information collected by internal audits and the corrective actions are not discussed in sufficient detail in meetings to ensure any outstanding matters are addressed with sign-off when completed. ii).Annual satisfaction surveys have not been implemented since 2023. iii). Non-clinical internal audits had not been signed off as completed on the day of audit. iv). Not all corrective actions identified at internal audits were evidenced as being closed off. v). The management report to the Tr | i). Ensure internal audit results and corrective actions are discussed in sufficient detail in staff meetings. ii).Ensure annual resident and family satisfaction surveys are implemented as scheduled. iii). Ensure non-clinical internal audits are signed off when completed. iv).Ensure corrective actions are implemented and closed off when finalised. v). Ensure management reports to the trust include health and safety, complaints, human resource concerns or internal audit and corrective action inf | PA Moderate | 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 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). The organisational risk management plan, an electronic hazard register and a maintenance schedule have not been evidenced as updated or reviewed in 2024 or 2025. ii). There was no evidence registers are updated in response to new, emerging or changes in risk. | i). & ii). Ensure the organisational risk management plan, the electronic hazard register and maintenance schedule are evidenced as being reviewed at regular intervals and ongoing as new risks are identified. | PA Moderate | In Progress | |
| Service providers shall ensure the skills and knowledge required of each position are identified and the outcomes, accountability, responsibilities, authority, and functions to be achieved in each position are documented. | Two of five staff files reviewed did not have a position description in file. | Ensure all staff have signed position descriptions on file. | PA Low | In Progress | |
| A medication management system shall be implemented appropriate to the scope of the service. | i). One controlled medication (oxycodone) was not documented in the reference index of the controlled drug register. ii). The controlled drug register reference index identified the medication name and dosage; however, six entries did not record the name of the rest home resident. iii). The controlled drug register did not accurately reflect current medications, eg: morphine liquid documented on two pages; however, only one bottle in the cupboard. iv). Controlled drug register documentation did | i). Ensure that all controlled drugs transactions are documented in the index of the controlled drug register. ii) Ensure the controlled drug index records the medication and the resident’s name. iii). Ensure the controlled drug register accurately reflects the controlled medications on site. iv) Ensure all controlled medication administration reflect two signatures of staff who have completed medication competencies related to controlled drug administration. v) Complete stock takes of the co | PA High | In Progress | |
| Service providers shall ensure there is a system to identify, plan, facilitate, and record ongoing learning and development for health care and support workers so that they can provide high-quality safe services. | i). This audit could not evidence that caregivers have completed training relevant to their role (and the NZS 8134:2021) in the past two years to meet the ARRC contract clause D17.7. ii). Competencies have not been completed annually as per policy for medication, hand hygiene, cultural safety and PPE. iii). The manager was unable to evidence training related to aged care facility management for 2025. iv). Training was not evidenced for the following subjects documented as annual training: code | i).Ensure caregivers training evidence meets the ARRC Contract clause D17.7 ii).Ensure competencies are completed annually as scheduled. iii).Ensure the manager completes education related to aged care facility management. iv).Ensure all required training is provided as scheduled. | 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. | i).Two of five staff files reviewed did not have evidence of an orientation on file. ii). One of three orientations on file was not fully completed. | I – ii). Ensure fully completed orientation is evidenced for all staff. | PA Moderate | In Progress | |
| Service providers ensure competent health care and support workers manage medication including: receiving, storage, administration, monitoring, safe disposal, or returning to pharmacy. | i).Medication competencies have not been completed annually for eight of nine caregivers who administer medications. ii).The manager (caregiver) did not have a medication competency. | i-ii).Ensure that all managers and staff involved in medication administration have completed annual medication competencies. | PA High | In Progress | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | Three of three staff files reviewed who had been employed for over a year did not have a current performance appraisal on file. | Ensure appraisals are completed as per the schedule. | PA Moderate | In Progress | |
| A process shall be implemented to identify, record, and communicate people’s medicine related allergies or sensitivities and respond appropriately to adverse events. | A medication error identified in meeting minutes relating to controlled medication was not entered into the electronic adverse events or included in the quality reporting system. | Ensure all medication incidents are included in the quality reporting system | PA Moderate | In Progress | |
| My complaint shall be addressed and resolved in accordance with the Code of Health and Disability Services Consumers’ Rights. | i) Documented complaints did not evidence compliance with acknowledgement, investigation and outcome timeframes as per policy or health and disability commission guidelines. ii) The complaint process does not evidence investigation or outcome documentation. iii). A concern raised by family in July 2025 (documented in staff meeting minutes) was not documented in the complaints register. | i). Ensure complaints are responded to and outcomes concluded within policy and health and disability commission timeframes. ii). Ensure complaint acknowledgement, investigation and outcomes are documented. iii)Ensure all complaints are documented in the complaints register. | PA Moderate | In Progress | |
| Service providers shall facilitate safe self-administration of medication where appropriate. | i).One resident who self-administers their insulin did not have a self-medication competency. ii). Pre-filled Insulin syringes were stored on the residents overbed table in the residents room. | i).Ensure all residents who self-administer medications have a current competency on file as per policy. ii). Ensure medication of self-administering residents in stored securely in their rooms. | PA Moderate | In Progress | |
| Over-the-counter medication and supplements shall be considered by the prescriber as part of the person’s medication. | i).Stock medication (e.g.codral, kurols, antiflame etc) is available for use. ii) Over the counter medication is administered to residents without a prescription and without evidence that it is considered at medication review or as part of a nurse-initiated order. | i).Ensure there is no stock medication in use for rest home level care residents. ii). Ensure all over the counter medications are prescribed prior to administration. | PA Moderate | 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 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: Surveillance Audit
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
