Profile & contact details
|Premises name||Westella Homestead|
|Address||84 Waughs Road Aorangi Feilding 4775|
|Service types||Dementia care, Rest home care|
|Certification/licence name||C D Hodson - Westella Homestead|
|Current auditor||Health Audit (NZ) Limited|
|End date of current certificate/licence||31 July 2021|
|Certification period||24 months|
|Provider name||C D Hodson|
|Street address||Westella Homestead 84 Waughs Road Feilding 4775|
|Post address||PO Box 455 Feilding 4740|
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 June 2019
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|The organisation plans to ensure Māori receive services commensurate with their needs.||Residents who identify as Maori did not receive services that commensurate with their needs.||Provide evidence that advisory groups are consulted where appropriate and Maori health care plans are developed where required.||PA Low||Reporting Complete||11/07/2019|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||There was no evidence that the CTL was given specific orientation relevant to the manager’s role.||Provide evidence that the CTL has been orientated to the manager’s role.||PA Moderate||Reporting Complete||11/07/2019|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||There was no evidence provided to show that the Diversional Therapist had a current first aid certificate.||Provide documented evidence that the Diversional Therapist has undergone first aid training.||PA Low||Reporting Complete||11/07/2019|
|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.||The registered nurses had not reviewed residents progress regularly and document in progress notes.||Provide evidence that the registered nurses document residents’ progress and review in progress notes on a regular basis.||PA Moderate||Reporting Complete||11/07/2019|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i) There was no documented short-term care plan in place for one resident with chest infection. (ii) Neurological observations had not been completed as per policy for three residents with unwitnessed falls.||(i) Provide evidence that care plans are updated as per residents assessed needs. (ii) Provide evidence that neurological observations are completed for unwitnessed falls as per policy.||PA Moderate||Reporting Complete||11/07/2019|
|The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.||The gate and the other supporting structure on the stairway were too low for residents’ safety.||Provide evidence that the stairway access is safe for residents.||PA Moderate||Reporting Complete||11/07/2019|
|There are adequate numbers of accessible toilets/showers/bathing facilities conveniently located and in close proximity to each service area to meet the needs of consumers. This excludes any toilets/showers/bathing facilities designated for service providers or visitor use.||Wall surfaces in most shower/bathing facilities were not consistent with infection control requirements.||Provide evidence that the wall surfaces are repaired and regularly maintained.||PA Low||Reporting Complete||11/07/2019|
|The methods, frequency, and materials used for cleaning and laundry processes are monitored for effectiveness.||There was no clear demarcation of clean and dirty areas in the laundry.||Provide evidence that there are marked demarcations in the laundry for clean and dirty areas.||PA Low||Reporting Complete||11/07/2019|
|The responsibility for infection control is clearly defined and there are clear lines of accountability for infection control matters in the organisation leading to the governing body and/or senior management.||The registered nurse did not have a signed appointment letter to the role and an accompanying job description defining lines of accountability.||Provide evidence that a signed appointment letter and job description are in place.||PA Low||Reporting Complete||11/07/2019|
|The responsibility for restraint process and approval is clearly defined and there are clear lines of accountability for restraint use.||The clinical team leader is appointed to oversee the restraint role however it was noted that there was no signed appointment letter and job description evidenced on file.||Provide evidence that a signed appointment letter and job description are in place.||PA Low||Reporting Complete||11/07/2019|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Four of five care plans reviewed (dementia level of care) did not reflect the resident’s current interventions and needs/supports for the following; (i) four residents with mood and challenging behaviours as triggered in the assessment had insufficient interventions addressing management of mood and challenging behaviour, identification of triggers and de-escalation techniques. (ii) two dementia level of care residents with high falls risk as identified in the assessment. (iii) one resident wi… (this text has been trimmed due to space limits).||Provide evidence that care plans reflect the resident’s current needs/supports to meet the resident goals.||PA Moderate||Reporting Complete||11/07/2019|
|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.||Results of infection control data are not evidenced in minutes of staff meetings.||Provide evidence that infection control data is presented at staff meetings.||PA Low||Reporting Complete||11/07/2019|
|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.||Medication charts reviewed did not have documented evidence of the effectiveness of PRN medication administered.||Provide evidence that the effectiveness of PRN medication administered is documented after use.||PA Moderate||Reporting Complete||15/07/2019|
|Information of a private or personal nature is maintained in a secure manner that is not publicly accessible or observable.||Records of past care plans and interRAI assessments were being destroyed.||Provide evidence that residents’ past records are kept for a period of 10 years as outlined in the Health (Retention of Health Information) Regulations 1996.||PA High||Reporting Complete||15/07/2019|
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: 06 June 2019
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit