Waverley House Rest Home

Profile & contact details

Premises details
Premises nameWaverley House Rest Home
Address 5 Lannie Place Greenmeadows Napier 4112
Total beds20
Service typesRest home care
Certification/licence details
Certification/licence nameWaverley Aged Care Limited - Waverley House Rest Home
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence22 September 2019
Certification period24 months
Provider details
Provider nameWaverley Aged Care Limited
Street address 5 Lannie Place Greenmeadows Napier 4112
Post addressPO Box 7404 Taradale Napier 4112

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: 28 July 2018

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
The infection control team/personnel and/or committee shall comprise, or have access to, persons with the range of skills, expertise, and resources necessary to achieve the requirements of this Standard.The infection control coordinator has not attended any formal infection control education to maintain knowledge and skills around current best practice. The infection control coordinator is required to maintain own knowledge in infection control practices by attending formal infection control education. PA LowIn Progress
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) Controlled drugs that were sighted in the controlled drug safe had not been entered into the register. This was completed on the day of audit and the pharmacist was contacted to collect and return the controlled drugs to the pharmacy. The risk was therefore reduced to moderate. 2) One new resident did not have a medication chart in place for seven days. The GP had been faxed of the admission. The RN advised the GP surgery had closed due to illness, however the service did not attempt to … (this text has been trimmed due to space limits).1) Ensure all controlled drugs are entered into the controlled drug register and checked weekly. 2) Ensure medications are charted on admission. PA ModerateReporting Complete30/04/2018
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Mandatory training not completed during the two-year period was: Cultural awareness, Treaty of Waitangi, infection control, care planning, sexuality/intimacy, health and safety and also spirituality/counselling. Ensure that all mandatory training is provided within the required two-year period. PA LowReporting Complete30/11/2018
Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.There was not sufficient emergency stored water available on-site for 20 residents for three litres of water per resident, over three days. There was 90 litres of stored water on-site and not the 180 litres of water required. Ensure that there is 180 litres of water on-site for 20 residents for three litres of water over three days. PA LowReporting Complete06/12/2018
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.1) Care plans for two residents did not document interventions to meet the residents’ current needs/supports as follows: (i) the care plan had not been updated for a resident transferred back to the facility post fractured hip, to include the surgical wound, moderate falls risk interventions and pain management and (ii) there were no documented falls prevention interventions for a resident with a high falls risk. 2) There were no documented risks associated with the use of restraint for three o… (this text has been trimmed due to space limits).1) Ensure care plans reflect the needs/supports and interventions to meet the residents’ current health status. 2) Ensure risks identified for restraint use is documented in care plans. PA ModerateReporting Complete06/12/2018

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. 

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.

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