Lady Wigram Village
Profile & contact details
|Premises name||Lady Wigram Village|
|Address||210 Kittyhawk Avenue Wigram Christchurch 8042|
|Service types||Dementia care, Rest home care, Geriatric|
|Certification/licence name||Lady Wigram Limited - Lady Wigram Village|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||02 November 2024|
|Certification period||36 months|
|Provider name||Lady Wigram Limited|
|Street address||210 Kittyhawk Avenue Wigram Christchurch 8042|
|Post address||210 Kittyhawk Avenue Wigram Christchurch 8042|
Progress on issues from the last audit
What’s on this page?
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.
Details of corrective actions
Date of last audit: 14 September 2021
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||(1) Orientation documentation was not found in four (three registered nurses and one caregiver) of nine staff files reviewed and one orientation package was not signed off and received within the required timeframe. (2) All staff files reviewed did not have a 90-day performance review completed as per policy. (3) The infection control coordinator did not have a job description for infection control to describe her role and responsibilities.||(1) Provide evidence that orientation has occurred, and orientation is completed within the stated timeframe. (2) Establish a formal process to complete 90-day performance reviews/evaluation as per the in-house policy. (3) Ensure the job description to describe the roles and responsibilities of the infection control coordinator is on file.||PA Low||Reporting Complete||19/01/2022|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||(1) One hospital resident with challenging behaviours did not have resident specific de-escalation and diversion strategies documented in the care plan. (2) There were no interventions, preferences or affiliations documented in the care plan for one hospital level resident who identified as Māori. (3) Two hospital residents did not have interventions or comfort measures around infections documented. (4) One hospital resident admitted for end-of-life care did not have an end-of-life care plan d… (this text has been trimmed due to space limits).||(1)-(9) Ensure all care plan interventions are current, individualised and are included in the appropriate care plans.||PA Moderate||Reporting Complete||19/01/2022|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i) Two wound charts reviewed had more than one wound documented on the chart. (ii) Five of eleven wound charts reviewed did not consistently document progression or deterioration towards healing.||(i) Ensure all wounds have individual wound charts documented. (ii) Ensure wound evaluations documents progression towards healing.||PA Low||Reporting Complete||19/01/2022|
|Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include: (a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk; (b) A process that addresses/treats the risks associated with service provision is developed and im… (this text has been trimmed due to space limits).||Three incidents of residents in the dementia unit absconding through a fire door had not been formally documented on a hazard identification form and in the hazard register.||Ensure all hazards are identified and included on the hazard register actions implemented to mitigate the risk.||PA Low||Reporting Complete||26/01/2022|
The outcome required by the Health and Disability Services Standards.
Found at audit
The issue that was found when the rest home was audited.
The action necessary to fix the issue, as decided by the auditor.
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.
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.
Before you begin
Before you download the audit reports, please read our guide to rest home certification and audits which gives an overview of the auditing process and explains what the audit reports mean.
What’s on this page?
Audit reports for this rest home’s latest audits can be downloaded below.
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.
Prior to 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) will appear on the rest home’s page. As the rest home completes the required actions, the status on the web site will update.
Audit reportsAudit date: 14 September 2021
Audit type:Certification Audit
Audit type:Partial Provisional Audit
Audit type:Partial Provisional Audit