Living Waters Rest Home

Profile & contact details

Premises details
Premises nameLiving Waters Rest Home
AddressGround floor 136 Great North Road Otamatea Whanganui 4500
Websitehttps://www.eldernet.co.nz/Facilities/Rest_Home_Care/Virginia_Lodge/Service/DisplayService/FaStID/11451
Total beds21
Service typesRest home care
Certification/licence details
Certification/licence nameLiving Waters Medical Solutions Limited - Living Waters Rest Home
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence22 March 2025
Certification period36 months
Provider details
Provider nameLiving Waters Medical Solutions Limited
Street address5 Rakau Road Castlecliff Whanganui 4501
Post address5 Rakau Road Castlecliff Whanganui 4501

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: 20 January 2022

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk.Four of six incident forms for residents with an unwitnessed fall and/or who had hit their head did not have neurological observations taken as per policy. Ensure that neurological observations are taken as per policy. PA ModerateReporting Complete25/05/2022
All buildings, plant, and equipment comply with legislation.Hot water temperatures in the shared ensuites had consistently been above 45 degrees Celsius for the last six months. Temperatures ranged between 46-49 degrees Celsius with no evidence of correction actions taken. The risk is considered low as the plumber adjusted the hot water system in the shared ensuites on the day of audit. Ensure hot water temperatures in resident areas are maintained below 45 degrees Celsius. PA LowReporting Complete25/05/2022
The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.Worksafe, HealthCERT and the DHB were not notified of a serious incident that occurred for one staff member until the day of audit. Escalate any serious events as per Worksafe and contractual specifications. PA LowReporting Complete21/06/2022
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.Quality/staff meeting minutes do not evidence discussion of data with improvements put in place in response to issues raised. Ensure that the quality/staff meeting minutes evidence discussion of data with a corrective action plan documented if required and documentation of resolution of the issues. PA LowReporting Complete14/07/2022
There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.i). The on-call staff are not always responding to phone calls. ii). Staff are not always able to be replaced when on leave. i). Train on-call staff to ensure that they respond to calls in a timely manner with monitoring of calls and response times to ensure that this occurs. ii). Review caregiver roles and recruit into positions to ensure that there are sufficient staff on duty to manage workload and acuity. PA ModerateReporting Complete14/07/2022
Professional qualifications are validated, including evidence of registration and scope of practice for service providers.None of the five staff files reviewed had evidence that reference checks had been completed. Ensure that reference checks are completed prior to appointment of a staff member. PA LowReporting Complete14/07/2022
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Three of six staff files reviewed did not have a current annual performance appraisal. Ensure that each staff member has an annual performance appraisal completed. PA LowReporting Complete14/07/2022
During a temporary absence a suitably qualified and/or experienced person performs the manager's role.Cover for the CNM has not been organised should the CNM be on leave. Organise a second in charge for the CNM (registered nurse) should they be on leave. PA LowReporting Complete20/07/2022

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. 

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.

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