Profile & contact details
|Premises name||Wairarapa Village|
|Address||140 Chapel Street Masterton 5810|
|Service types||Rest home care, Geriatric, Medical, Physical|
|Certification/licence name||Wairarapa Village Limited - Wairarapa Village|
|Current auditor||Central Region's Technical Advisory Services Limited|
|End date of current certificate/licence||30 June 2020|
|Certification period||36 months|
|Provider name||Wairarapa Village Limited|
|Street address||49/140 Chapel Street Masterton 5810|
|Post address||PO Box 166 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: 04 December 2018
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|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.||Not all the current polices have been updated and reviewed as per the review policy and still reflect the previous owners practice. None of the current policies and procedures address the specific needs and aspirations of the younger people who reside at the facility and the quality system does not include initiatives to ensure continuous improvements for this group.||Ensure all policies are updated and reviewed to reflect the current ownership and service management. Develop relevant policies and procedures to ensure involvement in quality activity occurs for the group of younger residents.||PA Moderate||Reporting Complete||10/10/2017|
|Adequate space is provided to allow the consumer and service provider to move safely around their personal space/bed area. Consumers who use mobility aids shall be able to safely maneuvers with the assistance of their aid within their personal space/bed area.||Not all rooms that are reported to be designated dual purpose, are large enough to deliver all hospital level services, if the use of some mobility equipment is indicated to meet residents’ assessed needs. There is a policy framework in place to guide staff with room allocation to enable appropriate service delivery.||Work with the DHB to clarify room designations and make any required changes to ensure all rooms are able to provide the required services as per contractual agreements.||PA Low||Reporting Complete||10/10/2017|
|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.||Residents are not always reviewed monthly by the GP and no evidence was sighted to verify the GP has exempted the resident from requiring monthly reviews.||Evidence is provided to verify the GP supports any resident not requiring monthly visits.||PA Low||Reporting Complete||10/10/2017|
|The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.||The current Business Plan (2017), currently in draft, is focussed on the care of older people. There is no acknowledgement of the needs of the non-aged care residents at the facility in the philosophy or the goals of the plan.||Include in the vision and planning processes, a reflection of a person centred approach for this service that has specifics on the needs of people with physical disability.||PA Low||Reporting Complete||11/10/2017|
|The appointment of appropriate service providers to safely meet the needs of consumers.||i) Staff files reviewed did not all include current performance reviews. ii) There was no evidence that the changes in management roles were reported to HealthCERT.||i) All staff to have current performance reviews completed annually. ii) Ensure HealthCERT is notified of the changes in the management roles.||PA Low||Reporting Complete||27/02/2019|
|The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code.||i) The service does not currently maintain a complaints register. ii) Complaints management documentation is not completed as per Right 10 of the Code.||i) Maintain a complaints register, reflecting the management of all complaints. ii) Complaints management documentation to be completed as per Right 10 of the Code.||PA Low||Reporting Complete||27/02/2019|
|The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.||i) The business plan is not current. ii) The business plan does not include a specific service plan for the care of YPD residents.||i) Review the business plan. ii) Ensure the business plan includes specific service goals for services to YPD residents.||PA Low||Reporting Complete||06/08/2019|
|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.||i) Incident/accident reports for residents who experienced unobserved falls do not evidence neurological observations over 24 hours. ii) Post falls risks are assessments are not consistently recorded. iii) Registered nurse reviews of residents who fall do not consistently document the timeframes for when assessments and interventions were completed post fall.||i) Incidents/accident records for residents who have unobserved falls to evidence documentation of neurological observations over 24 hours. ii) Ensure post falls assessments are completed for residents who fall. iii) Ensure registered nurses document timeframes when assessments and interventions are completed post fall.||PA Moderate||Reporting Complete||06/08/2019|
|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 quality improvement data is analysed/evaluated. ii) There is no documented evidence that quality improvement data/outcomes is communicated to service providers. iii) Continuous improvement initiatives for YPD residents are not included in the quality system.||i) Document quality improvement analysis, evaluations and outcomes. ii) Ensure quality improvement data/outcomes are communicated to service providers. iii) Continuous improvement initiatives for YPD residents to be included in the quality system.||PA Low||Reporting Complete||06/08/2019|
|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.||i) Not all policies are current and some of the policies still refer to the previous provider. ii) Policies do not reflect the needs of YPD residents. iii) There is currently no system for the management of policies and/or document control.||i) Review all policies to reflect the current providers’ services. ii) Policies to reflect the needs to YPD residents. iii) Implement a system for the management of policies and to ensure appropriate document control.||PA Moderate||Reporting Complete||18/12/2019|
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: 04 December 2018
Audit type:Surveillance Audit
Audit type:Certification Audit