Lakewood Rest Home

Profile & contact details

Premises details
Premises nameLakewood Rest Home
Address 31 Horseshoe Lake Road Shirley Christchurch 8061
Total beds36
Service typesDementia care
Certification/licence details
Certification/licence nameLakewood Rest Home Limited - Lakewood Rest Home
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence14 December 2022
Certification period36 months
Provider details
Provider nameLakewood Rest Home Limited
Street address 31 Horseshoe Lake Road Shirley Christchurch 8061
Post address

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: 26 July 2021

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Advance directives that are made available to service providers are acted on where valid.All files reviewed evidenced the resuscitation decision for CPR had been made by a family member. There was no evidence of GP involvement in the resuscitation decision. Ensure relatives are not making ‘not for resuscitation’ decisions. PA LowReporting Complete11/02/2020
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.(i). Internal audits have not always been undertaken as per the schedule, examples include; medication audit (May), the behaviours that challenge audit and informed consent audit (June), and audits have not been reported to meetings (all monthly meetings). (ii). Monthly reviews and reports for infection control and incidents and accidents are not reported to meetings and action plans have not been followed up and signed off as completed. (i). Ensure that the internal audit schedule is undertaken as per schedule and outcomes reported to meetings. (ii). Ensure that the infection control and incident and accident action plans are reported to the meetings and that the action plans are followed up and signed off. PA LowReporting Complete11/06/2020
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.(i). A review of the last two years training evidenced that the following subjects have not been provided to staff; abuse and neglect, wound care, open disclosure, infection control and medication. (ii). The content of training provided has not been documented. (i)-(ii) Ensure that all training is provided, and the content of training is documented. PA ModerateReporting Complete11/06/2020
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.(i) The long-term care plan for one resident did not reflect the residents current dietary requirements as identified on the written evaluation; (ii) There was no diabetes management plan in place (signs/symptoms, treatment and management) for one insulin dependent diabetic; and (iii) There were no documented risks associated with the use of a restraint for one resident. Ensure the long-term care plan meets the current supports/needs for the resident. PA LowReporting Complete11/06/2020
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.(i). Wound assessments for five wounds reviewed included an initial size, but there were no further recordings to monitor the healing or non-healing process. Photographs taken did not demonstrate the size of the wound. One wound on an outer left ankle had not been identified as a stage two pressure injury from shoes. (ii). There was no behaviour chart in place to document behaviours as described in progress notes. The GP was required to review the resident and commence ‘as required’ me… (this text has been trimmed due to space limits).(i). Ensure wound sizes are taken and documented regularly throughout the healing process and ensure wounds are correctly identified and documented. (ii). Ensure behaviours of concern are documented on a behaviour monitoring chart to monitor the effectiveness of interventions. (iii). Ensure that 15-minute checks are completed for residents identified at risk. PA LowReporting Complete11/06/2020
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.i). There is no documented evidence that internal audit outcomes have been reported at staff meetings. ii). The 2019 and 2020 relative survey results have not been collated and therefore outcomes have not been discussed or documented in monthly reports or meeting minutes. i). Ensure internal audit outcomes are reported at monthly meetings. ii). The relative satisfaction survey results collated, analysed and communicated to relatives and staff. PA ModerateReporting Complete27/01/2022
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.The content of training or education topics has not been documented. Ensure that the content of education sessions is documented. PA ModerateReporting Complete27/01/2022
Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome.Two of four long term files reviewed evidence short term care plans. These had been developed for a chest infection, knee infection, weight loss and vomiting but have not been signed off as resolved. Ensure short term care plans are signed off as evaluated and/or resolved. PA LowReporting Complete27/01/2022

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. 

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 Health and Disability Services Standards.

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: 26 July 2021

Audit type:Surveillance Audit

Audit date: 30 October 2019

Audit type:Certification Audit

Audit date: 23 April 2018

Audit type:Surveillance Audit

Audit date: 22 September 2016

Audit type:Certification Audit

Audit date: 10 December 2015

Audit type:Surveillance Audit

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