Springvale Manor
Profile & contact details
| Premises name | Springvale Manor |
|---|---|
| Address | Single floor. 47 Treadwell Street Springvale Whanganui 4501 |
| Total beds | 27 |
| Service types | Dementia care, Rest home care |
| Certification/licence name | Living Waters Medical Solutions Limited - Springvale Manor |
|---|---|
| Current auditor | Health and Disability Auditing New Zealand Limited |
| End date of current certificate/licence | 16 September 2025 |
| Certification period | 24 months |
| Provider name | Living Waters Medical Solutions Limited |
|---|---|
| Street address | 5 Rakau Road Castlecliff Whanganui 4501 |
| Post address | 5 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: 06 July 2023
| Outcome required | Found at audit | Action required | Risk rating | Action status | Date action reported complete |
|---|---|---|---|---|---|
| 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). | Resident’s individual wishes and family/ whānau communications were not always documented, and care plan interventions lacked evidence around family/whānau support, self-advocacy, and updated changes to care requirements. | Ensure that resident and family/whānau communications are recorded in the resident’s file, including interventions around family/whānau support, self-advocacy, and changes to care needs to achieve pae ora goals | PA Moderate | Reporting Complete | 16/02/2024 |
| Buildings, plant, and equipment shall be fit for purpose, and comply with legislation relevant to the health and disability service being provided. The environment is inclusive of peoples’ cultures and supports cultural practices. | Several maintenance issues were identified on the day of audit. The facility manager is aware of them and there is a plan in place to address these. | Ensure that the preventative maintenance plan is implemented. | PA Low | In Progress | |
| Where required by legislation, there shall be a Fire and Emergency New Zealand- approved evacuation plan. | 1. There is no documentation available to support that the evacuation plan has been approved by FENZ. 2. The fire evacuation processes outlined in the fire evacuation plan cannot be carried out due to the rusted door between the unit and the evacuation area designated in the evacuation plan. | 1-Ensure that the fire evacuation scheme is approved by FENZ. 2- Ensure that the door allowing cell evacuation from the dementia unit in the event of an emergency is operational. | PA Moderate | In Progress | |
| Service providers shall implement policies and procedures underpinned by best practice that shall include: (a) The process of holistic assessment of the person’s care or support plan. The policy or procedure shall inform the delivery of services to avoid the use of restraint; (b) The process of approval and review of de-escalation methods, the types of restraint used, and the duration of restraint used by the service provider; (c) Restraint elimination and use of alternative interventions shall … (this text has been trimmed due to space limits). | A holistic assessment prior to the implementation of the restraint was not completed. | Ensure that a holistic assessment is completed prior use of restraint. | PA Low | In 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. | Care planning activities do not meet the required timeframes, and consultation with residents and/or their families/whānau in relation to care planning was not documented. | Ensure that care plans are developed within the required timeframes and that these are completed and documented in consultation with the resident and/or their family/whānau. | PA Moderate | Reporting Complete | 13/12/2023 |
| 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). | 1- Cultural assessments are not completed by a culturally competent person and care plans lack interventions around resident’s lived experiences, cultural values, and preferences. 2- Resident records related to medical notes, and laboratory results are not accessible to staff to coordinate and provide ongoing clinical care management 3-InterRAI assessments, MDS comments, and the assessment summary were not kept in the resident’s file. | 1-Ensure that cultural assessments are completed by a culturally competent person and care plan interventions include residents’ cultural values, preferences, and their lived experiences. 2- Ensure medical notes and test results are integrated in the resident records 3- Ensure that the resident’s interRAI assessments are accessible by the RN. | PA Moderate | Reporting Complete | 16/02/2024 |
| Service providers ensure competent health care and support workers manage medication including: receiving, storage, administration, monitoring, safe disposal, or returning to pharmacy. | 1- Medication room temperatures are not monitored. 2- PRN medications including antipsychotic drugs were administered without nursing assessment with no follow-up on outcomes by the RN. | 1- Ensure that the medication room temperature is monitored and documented. 2- Ensure that PRN medications are administered following consultation with the RN and that the use of PRN medication is reviewed for efficacy. | PA Moderate | Reporting Complete | 16/02/2024 |
| Service providers shall ensure the quality and risk management system has executive commitment and demonstrates participation by the workforce and people using the service. | There is no evidence of corrective actions following audits being followed up, evaluated, and signed off to demonstrate compliance with policy. | Ensure that corrective actions are evaluated. | PA Low | Reporting Complete | 16/02/2024 |
| Service providers shall understand Māori constructs of oranga and implement a process to support Māori and whānau to identify their own pae ora outcomes in their care or support plan. The support required to achieve these shall be clearly documented, communicated, and understood. | Two Māori resident’s files reviewed did not include information about Māori tikanga or pae ora outcomes for the resident. Care plans lacked culturally specific documentation and interventions to address individual resident’s needs. | Ensure that care plans are developed with Māori residents and their whānau to include the resident’s pae ora outcomes. Care plans are to be developed that are culturally appropriate to ensure interventions are clearly documented, communicated and understood. | PA Moderate | Reporting Complete | 16/02/2024 |
| 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. | The annual education programme since last audit has not been fully implemented. | Provide evidence that education and training is being conducted for all staff as per annual education and training plan. | PA Low | Reporting Complete | 16/02/2024 |
| 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). | Care plans were not reviewed on a timely basis, and short-term care plans were not developed for acute changes. The restraint used has not been evaluated as required in over twelve months. | Ensure that care plan evaluations are completed in a timely manner, and that resident’s acute health changes are addressed and documented. Ensure that restraint evaluations are completed and include items identified in criterion 6.2.7. | PA Moderate | Reporting Complete | 16/02/2024 |
| The physical environment, internal and external, shall be safe and accessible, minimise risk of harm, and promote safe mobility and independence. | There was minimal independent access to the secure external area for residents residing in the secure dementia unit, particularly in the area adjacent to the main lounge/recreation area. Independent access into the secure external area was discouraged. | Ensure that residents in the secure dementia unit have independent access to outdoor areas from the main lounge/recreation area of the unit. | PA Moderate | Reporting Complete | 27/02/2024 |
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | 1-There was no documented evidence of resident family/whānau meetings since the last audit. 2-There was no documented evidence of a family/whānau annual satisfaction for 2022. 3-The incident forms were completed by caregivers but there was a lack of documented evidence of RN follow-up after incidents and accidents. Families were not always updated following incidents for six of thirteen incident reports reviewed for May and June 2023. | 1-Ensure that the resident and whānau meetings occur as planned. 2- Ensure to provide evidence of family/whānau participation and feedback to the service. 3- Ensure that incident and accidents are followed up by the RN including whanau being kept informed of changes in resident needs. | PA Low | Reporting Complete | 12/03/2024 |
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: 06 July 2023Audit type:Certification Audit
Audit date: 23 May 2022Audit type:Provisional Audit