Lansdowne Park Village
Profile & contact details
|Premises name||Lansdowne Park Village|
|Address||100 Titoki Street Lansdowne Masterton 5810|
|Service types||Geriatric, Medical, Rest home care|
|Certification/licence name||Lansdowne Park Village Limited - Lansdowne Park Village|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||18 October 2018|
|Certification period||24 months|
|Provider name||Lansdowne Park Village Limited|
|Street address||100 Titoki Street Lansdowne Masterton 5810|
|Post address||PO Box 1 Masterton 5840|
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 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||There is no evidence of quality data and incident/accident trends analysis being discussed at staff meetings. Meeting minutes reviewed showed that follow-up corrective actions have not always been documented as completed.||Ensure that quality data and incident/accident trends analysis is discussed at staff meetings. Ensure that any corrective actions follow-up from meetings are documented as completed||PA Low||Reporting Complete||23/02/2017|
|Service delivery plans demonstrate service integration.||There was no documented evidence of resident/relative involvement in the development of care plans for two hospital and four rest home residents.||Ensure there is documented evidence of resident/relative involvement in the development of care plans.||PA Low||Reporting Complete||23/02/2017|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||There was no documented evidence/records to reflect that two yearly education/training for the following mandatory education topics; abuse and neglect, complaints, open disclosure, nutrition/hydration, pain management, end of life, sexuality/intimacy, wound care and pressure injury prevention has been completed. Noting these are scheduled for 2016.||Ensure that education/training is provided on the mandatory education/training topics and records are maintained.||PA Low||Reporting Complete||24/02/2017|
|Each episode of restraint is documented in sufficient detail to provide an accurate account of the indication for use, intervention, duration, its outcome, and shall include but is not limited to: (a) Details of the reasons for initiating the restraint, including the desired outcome; (b) Details of alternative interventions (including de-escalation techniques where applicable) that were attempted or considered prior to the use of restraint; (c) Details of any advocacy/support offered, provided o… (this text has been trimmed due to space limits).||Interventions to manage the risks are not documented in the long-term care plans for three of three residents (on restraint) files reviewed.||Ensure that interventions to manage assessed risks are documented in the long-term care plans for residents on restraint.||PA Low||Reporting Complete||02/03/2017|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||There were no interventions implemented for the following; a) two hospital residents with weight loss, b) one rest home resident with identified pain and elimination problems and c) there were no neurological observations for eight unwitnessed falls as per policy.||Ensure monitoring charts are completed when identified, as required in care plans.||PA Moderate||Reporting Complete||02/03/2017|
|A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines.||(1) There were no indications for use for ‘as required’ medication (codeine, morphine, tramadol, ibrufen, and loperamide) prescribed on five of 16 medication charts. (2) Four of 16 medication charts had not been documented as reviewed by the GP at least three monthly.||(1) Ensure all ‘as required’ medication have a prescribed indication for use. (2) Ensure medication charts are reviewed by the GP at least three monthly.||PA Low||Reporting Complete||02/03/2017|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||Six staff files were reviewed. Four of six staff files did not have an up-to-date performance appraisal completed.||Ensure that all staff performance appraisals are completed annually.||PA Low||In Progress|
|Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer.||Two hospital admissions did not have an interRAI assessment completed within 21 days of admission.||Ensure the first interRAI assessment is completed within 21 days of admission.||PA Low||In Progress|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||1) There were no interventions implemented for a hospital resident with weight loss. 2) Five of eleven wounds did not have a change of dressing at the documented frequency.||1) Ensure interventions are implemented for weight loss. 2) Ensure wounds have dressing changes as per the documented frequency.||PA Moderate||In Progress|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||1) Staff (three monthly) and quality (monthly) meetings were not completed as per the annual calendar schedule. There has been one staff meeting in July 2017 and one quality meeting in August 2017 documented since the last audit. 2) The minutes of the meetings held did not document evidence of quality data including; incident/accident and infection control trends and analysis.||1) Ensure that staff and quality meetings are completed as per the annual calendar schedule. 2) Ensure that quality data including trends and analysis of incident/accident and infection control is documented in meeting minutes.||PA Moderate||In Progress|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||(1) Three resident care plans (two hospital and one rest home) did not document appropriate pressure injury interventions to meet the assessed level of risk. (2) Three resident care plans (one hospital and two rest home) did not document appropriate falls prevention strategies to meet the assessed level of risk. (3) There was no diabetic management plan in place for one insulin dependent rest home resident.||Ensure care plan interventions clearly include all supports to meet the resident’s current health status.||PA Moderate||Reporting Complete||02/11/2017|
|A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines.||There was no oxygen prescribed for one hospital resident on continuous oxygen therapy.||Ensure oxygen therapy is prescribed.||PA Low||Reporting Complete||19/01/2018|
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.
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 reportsAudit date: 14 September 2017
Audit type:Surveillance Audit
- Lansdowne Park Village - Sep 2017 (docx, 33.92 KB)
- Lansdowne Park Village - Sep 2017 (pdf, 132.84 KB)
Audit type:Certification Audit
- Lansdowne Park Village - Aug 2016 (docx, 43.5 KB)
- Lansdowne Park Village - Aug 2016 (pdf, 167.84 KB)
Audit type:Surveillance Audit
- Lansdowne Park Village - Feb 2015 (docx, 50.55 KB)
- Lansdowne Park Village - Feb 2015 (pdf, 143.4 KB)
Audit type:Certification Audit
- Lansdowne Park Village - Sep 2013 (docx, 178.7 KB)
- Lansdowne Park Village - Sep 2013 (pdf, 500.58 KB)
Audit type:Partial Provisional Audit