Lady Wigram Village

Profile & contact details

Premises details
Premises nameLady Wigram Village
Address 210 Kittyhawk Avenue Wigram Christchurch 8042
Websitehttps://ladywigram.co.nz/
Total beds140
Service typesGeriatric, Medical, Dementia care, Rest home care
Certification/licence details
Certification/licence nameLady Wigram Limited - Lady Wigram Village
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence02 November 2024
Certification period36 months
Provider details
Provider nameLady Wigram Limited
Street address210 Kittyhawk Avenue Wigram Christchurch 8042
Post address210 Kittyhawk Avenue Wigram Christchurch 8042
Websitehttps://ladywigram.co.nz/

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: 11 January 2024

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Service providers shall evaluate progress against quality outcomes.i). Quality improvement, staff and RN/clinical meetings have not been held as per the required schedule policy. ii). Not all agenda items, discussion points and actions have been followed up or completed. i). Ensure that quality improvement, staff and RN/clinical meetings are held as per the required schedule policy. ii). Ensure all agenda items, discussion points and actions are evidenced as followed up and completed. PA LowIn Progress
Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care.Twenty-eight internal audits were reviewed, eighteen internal audits requiring corrective actions were not fully actioned or signed off as closed. Ensure that all corrective actions are followed up and closed out. PA ModerateIn Progress
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). Three of eight files reviewed did not have a long-term care plan documented within three weeks of admission (two files did not require long term care plans). ii). InterRAI assessments were not completed within 21 days of admission for two of four residents who required interRAI assessments. iii). InterRAI reassessments were not completed as scheduled for two of three residents where reviews were required over the previous year. iv). Six-monthly evaluations were not completed within require… (this text has been trimmed due to space limits). i). Ensure long-term care plans are documented with 21 days of admission. ii). Ensure initial interRAI assessments are completed within three weeks of admission. iii). Ensure interRAI reassessments are completed six-monthly. iii). Ensure care plan evaluations are completed at least six-monthly. PA ModerateIn Progress
A medication management system shall be implemented appropriate to the scope of the service.The temperatures of two medication rooms (rest home and dementia units) evidenced temperatures above 25 degrees on three and four occasions over recent weeks, with no corrective actions. Ensure medications rooms are monitored as per policy and corrective actions implemented when outside documented ranges. PA ModerateIn Progress
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… (this text has been trimmed due to space limits).i).Two hospital residents with ongoing pain had no non-pharmaceutical interventions documented to manage pain or discomfort. ii). One hospital level care resident assessed as a moderate falls risk did not have interventions documented to manage the risk. iii). One hospital level care resident assessed by speech language therapy as requiring a puree diet with upright positioning did not have interventions documented to manage the risk. i). - iii) Ensure all care plan interventions are current, individualised and reflect the assessed needs of residents. PA ModerateIn Progress
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… (this text has been trimmed due to space limits).Two of two repositioning charts reviewed for hospital residents did not evidence completion as planned. Ensure monitoring is completed as scheduled. PA ModerateIn 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.There was no evidence of mandatory training provided for the following: sexuality/intimacy, spirituality/counselling, the aging process, death/Tangihanga, advocacy, abuse and neglect, and privacy/dignity. Ensure that all two yearly mandatory training is conducted for all staff. PA LowIn Progress
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 … (this text has been trimmed due to space limits).Two of three care plan evaluations did not reflect progress towards the goals. Ensure that care plan evaluations reflect progress towards the goals. PA ModerateIn Progress
Governance bodies shall ensure service providers’ structure, purpose, values, scope, direction, performance, and goals are clearly identified, monitored, reviewed, and evaluated at defined intervals.There is a business plan in place; however, specific objectives/goals were not evidenced as being documented or reviewed annually or throughout the year. Ensure that the business plan has specific objectives/goals documented as reviewed annually and regularly throughout the year. PA LowIn 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

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 reports

Audit date: 11 January 2024

Audit type:Surveillance Audit

Audit date: 14 March 2023

Audit type:Surveillance Audit

Audit date: 14 September 2021

Audit type:Certification Audit

Audit date: 16 March 2021

Audit type:Partial Provisional Audit

Audit date: 15 October 2020

Audit type:Partial Provisional Audit

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