Premise details
- Address
- 24 Alma Street Wyndham 9831
- Total beds
- 23
- Service types
- Rest home care
Certification/licence details
- Certification/licence name
- Wyndham and Districts Community Rest Home Incorporated - Wyndham and District Community Rest Home
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 24 months
Provider details
- Provider name
- Wyndham and Districts Community Rest Home Incorporated
- Street address
- 24 Alma Street Wyndham 9831
- 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 |
|---|---|---|---|---|---|
| Service providers shall have a clearly defined and documented IP programme that shall be: (a) Developed by those with IP expertise; (b) Approved by the governance body; (c) Linked to the quality improvement programme; and (d) Reviewed and reported on annually. | The 2023 infection control programme has not been reviewed. | Ensure the infection control programme is reviewed annually. | 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). The satisfaction survey only asks residents if they are satisfied with care, activities, meals and cleaning/ laundry services. ii). RN meeting minutes do not reflect clinical discussions around analysis of quality data. iii). Staff meetings are not reflective of a). discussions around analysis of quality data, b). staff feedback, and c). any corrective actions resulting from internal audits/ previous meeting minutes, or quality data results. | i). Ensure satisfactions cover all aspects of services provided. ii). & iii). Ensure discussions held around quality data and corrective actions are reflected in meeting minutes. | PA Low | Reporting Complete | |
| Service providers shall evaluate progress against quality outcomes. | Corrective actions identified have not been signed off as completed. | Ensure corrective actions are signed off when completed. | PA Low | Reporting Complete | |
| 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 updated since 2022. | Ensure the hazard and risk register is reviewed at least annually. | PA Low | Reporting Complete | |
| Service providers shall implement systems to determine and develop the competencies of health care and support workers to meet the needs of people equitably. | i). There was no evidence of current medication competencies in place for staff who administer medications. ii). There was no evidence sighted of competencies completed for restraint, manual handling, and infection control (including standard precautions and hand hygiene). | i). & ii). Ensure all staff complete the required competencies annually. | PA Moderate | Reporting Complete | |
| 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). There is no structured education plan in place. ii). There was no evidence of education sessions, including abuse and neglect; aging process; sexuality; restraint; the aging process; privacy and dignity; complaints; oral hygiene; medication management; and continence, held in the last two years. | i). Ensure an education plan is documented. ii). Ensure all compulsory education sessions are held. | PA Moderate | Reporting Complete | |
| 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. | There is no signed job description on file for the roles of restraint and infection control coordinator. | Ensure job descriptions are signed and on file for extra roles, such as the infection control coordinator and the restraint coordinator. | PA Low | Reporting Complete | |
| My service provider shall practise open communication with me. | Family/whānau notifications were not consistently documented in incident forms or resident progress notes in files reviewed. | Ensure all communication with family/whānau is documented. | PA Low | Reporting Complete | |
| A medication management system shall be implemented appropriate to the scope of the service. | i). The controlled drug register does not evidence consistent weekly checks. ii). The six-monthly physical controlled drug stocktake have not been documented. | i-ii). Ensure controlled drug stock checks occur as per legislative requirements. | PA Moderate | 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 on an ACC respite contract admitted one week ago did not evidence completed initial assessments. ii). Two residents admitted one week and three months ago did not evidence a documented initial care plan. iii). Two residents did not have an initial interRAI completed within 21 days of admission. iv). Two residents did not have a care plan documented within 21 days of admission. v). Three of three residents requiring interRAI reassessments did not have these completed six-monthly. | i-vi) Ensure initial assessments, initial care plans, initial interRAI assessments, repeat interRAI assessments, initial long-term care plans, and six-monthly evaluations of care plans are documented within required timeframes. | 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 | i). Care plan interventions were not documented for two residents admitted one week and three months ago. ii). Care plan interventions were not documented in the current electronic system for one resident and were not available to care staff. iii). Interventions were not documented in the care plan for one resident with behaviours that challenge. iv). The interventions for safe use of restraint are not fully documented or implemented for one of one resident utilising bed rails as restraint. | i). – iv). Ensure all care plan interventions are current, reflect the assessed needs of residents, and are available to guide care staff. | PA Moderate | 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 | Four of four neurological observations reviewed have not been consistently monitored as per policy following unwitnessed falls or potential head injuries. | Ensure neurological observations are completed as per policy. | PA Low | Reporting Complete | |
| Surveillance methods, tools, documentation, analysis, and assignment of responsibilities shall be described and documented using standardised surveillance definitions. Surveillance includes ethnicity data. | i). Not all infections are entered into the infection register. ii). Monthly infections are not evidenced as collated and analysed by the infection control and prevention coordinator. | i). Ensure all infections are entered into the infection register. ii). Ensure monthly infections are collated and analysed with input from the IP & C coordinator. | PA Moderate | 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. | (i). There was no evidence of who is responsible to oversee the maintenance programme and complete the checklists. (ii). Not all electrical equipment has been tested and tagged as electrically compliant. (iii). Hot water temperatures throughout the facility were not documented as being checked. | (i). Ensure a responsible person is allocated to oversee the implementation of the maintenance programme. (ii). Ensure electrical equipment is tested as electrically compliant. (iii). Ensure hot water temperatures throughout the facility is documented and maintained below 45 degrees. | 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). Quality goals are documented but not reviewed quarterly as per the documented quality improvement plan. (ii). The internal audit schedule was not evidenced to be fully implemented as required since August 2024. (iii). Staff meetings and clinical review meetings are not reflective of restraint discussions and any corrective actions resulting from internal audits/ previous meeting minutes being shared with staff. (iv). Restraint discussions/data is not documented as reported to the Board. | (i)-(iii). Ensure key elements of the quality and risk management programme is documented as required related to reviewing of quality goals, completion of internal audits, documenting /discussions of corrective actions, and inclusion of restraint discussions. (iv). Ensure the Board report includes restraint discussions/data. | 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. | The service has not yet updated, reviewed and signed the hazard register (last signed in July 2024). | Ensure the hazard and risk register is reviewed at least annually. | PA Moderate | In Progress | |
| Service providers shall have a clearly defined and documented IP programme that shall be: (a) Developed by those with IP expertise; (b) Approved by the governance body; (c) Linked to the quality improvement programme; and (d) Reviewed and reported on annually. | The infection control programme has not been reviewed for 2024. | Ensure the infection programme is reviewed annually. | PA Moderate | 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). There is no structured education plan in place. (ii). There was no evidence of all required education sessions, including abuse and neglect; aging process; sexuality; privacy and dignity; complaints; oral hygiene; and continence, held in the last two years. | (i). Ensure an education plan is documented. (ii). Ensure all compulsory education sessions are held. | PA Moderate | In Progress | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | Three staff files reviewed who have been employed for a year or more, did not have a current performance appraisal on file. | Ensure staff who have been employed for more than one year has a staff performance appraisal on file. | 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 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
Audit date:
Audit type: Surveillance Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Surveillance Audit
