Springvale Manor Rest Home

Profile & contact details

Premises details
Premises nameSpringvale Manor Rest Home
Address 47 Treadwell Street Springvale Wanganui 4501
Total beds27
Service typesDementia care, Rest home care
Certification/licence details
Certification/licence nameSpringvale Manor Limited - Springvale Manor Rest Home
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence01 November 2022
Certification period24 months
Provider details
Provider nameSpringvale Manor Limited
Street address 47 Treadwell Street Springvale Wanganui 4501
Post addressPO Box 7100 Wanganui 4541

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: 02 November 2021

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
The organisation has a clearly defined and documented infection control programme that is reviewed at least annually.The infection control programme has not been reviewed annually. Ensure an annual review of the infection control programme is documented. PA LowReporting Complete23/07/2021
A process to measure achievement against the quality and risk management plan is implemented.(i). The quality plan/business plan does not include clear and timebound objectives to enable evaluation of progress. (ii). Internal audits have not been completed according to timeframes (i). Ensure that there are set and timebound goals/goals for the service (SMART objectives). (ii). Ensure the internal audit timeframes are complied with PA LowReporting Complete23/07/2021
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.The service has not provided all training as required by the ARRC contract over the last two years. Training not completed includes resident rights, advocacy / open disclosure, sexuality, pain management, privacy / dignity, and aging process. Ensure that a training programme for staff is implemented that complies with the ARRC contract. PA LowReporting Complete23/07/2021
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.Not all quality data analysis and outcomes are reported at meetings, this included health and safety information and restraint review information Ensure that all quality information is reported to the quality/staff meetings PA LowReporting Complete23/07/2021
All records pertaining to individual consumer service delivery are integrated.The resident files were not integrated with separate folders. All original short-term care plans and progress notes are stored in residents’ files. There are separate folders for current progress notes only and a “daily documentation file. Long-term care plans were not available in the resident file and were not readily available to staff. Three resident files did not have care plans in place. Since the draft report the manager has provided copies of missing care plans. Integrate resident files to include all service delivery records for the resident. PA LowReporting Complete23/07/2021
Service delivery plans demonstrate service integration.(i) Five of eight care plans reviewed (there were no care plans for three residents) did not document resident (as appropriate) or relative/EPOA input into the care plan. (ii) The long-term care plans did not include the involvement of allied health professionals in the care of the resident. (i) Ensure there is documented evidence of the resident/relative involvement in the care plan. (ii) Ensure involvement of allied health professionals are linked to the long-term care plan. PA LowReporting Complete23/07/2021
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.There was no six-monthly written evaluation for four of eight long-term care plans (one rest home and three dementia care). Ensure care plans are evaluated at least six-monthly for progress towards meeting the desired goals. PA LowReporting Complete23/07/2021
Consumers are given the choice and advised of their options to access other health and disability services where indicated or requested. A record of this process is maintained.There were two dementia care residents with declining mobility that required at times two person transfers and feeding as confirmed by caregivers and the RN on interview. These residents had not been referred for reassessment. Ensure referrals are made to the needs and assessment team for residents with declining mobility and health. PA LowReporting Complete23/07/2021
All buildings, plant, and equipment comply with legislation.(i) The annual calibration of equipment has not been documented for 2020. (ii) Hot water temperature monitoring was not able to be evidenced. (i): Ensure that the calibration of equipment is documented annually (ii). Ensure that hot water temperature monitoring is documented. PA LowReporting Complete23/07/2021
Alternative energy and utility sources are available in the event of the main supplies failing.There is not enough water stored for three litres per person per day for three days as required for this area Ensure there are sufficient water supplies stored. PA LowReporting Complete23/07/2021
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.(i) The three medications (glucagon and eye drops) kept in the fridge had expired. (ii) There were no standing orders in place authorised by the GP including the indications, contra-indications, timeframes and monitoring requirements for use. (iii) There were no weekly controlled drug checks completed. (iv) There was no monitoring of medication room air temperatures. (i) Ensure medications in the medication fridge are checked for expiry dates. (ii) Standing orders to comply with standing medication requirements. (iii) Ensure weekly controlled drug checks are completed by an RN and one other medication competent person. (iv) Ensure the medication room air is monitored. PA ModerateReporting Complete23/07/2021
Results of surveillance, conclusions, and specific recommendations to assist in achieving infection reduction and prevention outcomes are acted upon, evaluated, and reported to relevant personnel and management in a timely manner.Only infections that are treated with antibiotics are collected as infection data. Ensure that all infections are collected as per the service policy. PA LowReporting Complete23/07/2021
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.(i) Two initial interRAI assessments (one rest home and one dementia care) were not completed within 21 days of admission. (ii) Two long-term care plans (one rest home and one dementia care) had not been developed within three weeks of admission. (iii) Two routine interRAI assessments from the extended sample (dementia care) were not competed six monthly or earlier due to health change. (iv) Four long-term care plans reviewed (one rest home and three dementia care), including the extended sam… (this text has been trimmed due to space limits).(i) Ensure initial interRAI assessments are completed within 21 days of admission. (ii) Ensure long-term care plans are developed within three weeks of admission. (iii) Ensure routine interRAI assessments are competed six monthly or earlier for health changes. (iv) Ensure all long-term care plans are evaluated six monthly or earlier due to health changes. (v) Ensure all residents have long-term care plans in place. PA ModerateReporting Complete23/07/2021
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.(i). Four care plans (one rest home and three dementia care) had not been updated to meet the resident’s current needs and supports as follows: a) there were no documented interventions for a rest home resident with cardiorespiratory problems and osteoarthritic pain as identified in the interRAI assessment, b) there were no documented interventions for one dementia care resident assessed as high falls risk and risk of undernutrition, c) there were no documented interventions for one dementia car… (this text has been trimmed due to space limits).(i) Ensure care plans are updated to reflect the resident’s current needs and supports. (ii) Ensure all residents with dementia have a 24-hour behaviour management plan in place. (iii) Ensure all residents have a current long-term care plan. (iv) Ensure the risks associated with the use of restraint is documented in long-term care plans. PA ModerateReporting Complete23/07/2021
The service develops and implements policies and procedures that are aligned with current good practice and service delivery, meet the requirements of legislation, and are reviewed at regular intervals as defined by policy.Policies have not been reviewed and updated within reasonable timeframes examples include sexuality (2015), infection control (2012) and pressure injury (2003). Ensure that there are a range of up to date polices to comply with the ARRC contract and best practice. PA LowReporting Complete23/07/2021
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.There was no current six-monthly written evaluation for one rest home and two dementia long-term care plans. Ensure care plans are evaluated at least six-monthly for progress towards meeting the desired goals. PA LowIn 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.(i) Two initial interRAI assessments (one rest home and one dementia care) were not completed within 21 days of admission. (ii) Three routine interRAI assessments (one rest home and two dementia care) were not competed six monthly or earlier due to health change. (iii) Three long-term care plans reviewed (one rest home and two dementia care), had not been evaluated six monthly or earlier due to health changes. (iv) There were no long-term care plans for two residents (one rest home and one … (this text has been trimmed due to space limits).(i). Ensure initial interRAI assessments are completed within 21 days of admission. (ii). Ensure routine interRAI assessments are competed six monthly or earlier for health changes. (iii). Ensure all long-term care plans are evaluated six monthly or earlier due to health changes. (iv0. Ensure all residents have long-term care plans in place. PA ModerateIn Progress
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.(i) One dementia care plan had not been updated to meet the resident’s current needs and supports related to signs and symptoms of chest pain and the care of a supra-pubic catheter. (ii) There were no long-term care plans in place for two residents (one rest home and one dementia care). (iii) Risks and interventions associated with the use of restraint were not documented. (i) Ensure care plans are updated to reflect the resident’s current needs and supports. (ii) Ensure all residents have a current long-term care plan. (iii) Ensure all risks and interventions associated with restraint use are documented PA ModerateReporting Complete29/03/2022
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.Eight wounds reviewed for six dementia level residents did not have a wound assessment or wound care plan. Ensure all wounds are assessed and a plan of care documented as per policy. PA ModerateReporting Complete26/04/2022
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.Not all quality data analysis and outcomes are reported at meetings, this included health and safety information, incidents, accidents, and restraint review information. Ensure that all quality information is reported to the quality/staff meetings. PA ModerateReporting Complete26/04/2022

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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