Westmar 2021

Profile & contact details

Premises details
Premises nameWestmar 2021
Address12 Kimberley Road Darfield 7510
Total beds28
Service typesDementia care, Rest home care
Certification/licence details
Certification/licence nameWestmar 2021 Limited - Westmar 2021
Current auditorBSI Group New Zealand Ltd
End date of current certificate/licence30 April 2025
Certification period36 months
Provider details
Provider nameWestmar 2021 Limited
Street address12 Kimberley Road Darfield 7510
Post address12 Kimberley Road Darfield 7510

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: 08 August 2023

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.(i). It was difficult to ascertain the attendance numbers for topics completed online. (i). Ensure a consistent process of documenting attendance numbers for topics completed online. PA LowReporting Complete07/07/2022
The organisation identifies and implements appropriate security arrangements relevant to the consumer group and the setting.(i). The door to the current dementia unit is secured and will need to be disarmed. (ii). The new entry door is in place with a lock but not yet activated. (i). The current door needs to be deactivated. (ii). Ensure the new relocated door is secure and activated to incorporate the extension of the six beds. PA LowReporting Complete07/07/2022
All buildings, plant, and equipment comply with legislation.(i). Hot water temperatures were not consistently recorded. There were no documented recordings for 2022. (ii). There was no maintenance schedule for 2022 and no documented planned maintenance signed as completed. (i)-(ii) Ensure that all hot water temperatures are consistently checked and recorded and that the maintenance schedule for 2022 is actioned and planned maintenance completed. PA LowReporting Complete07/07/2022
Service providers maintain professional boundaries and refrain from acts or behaviours which could benefit the provider at the expense or well-being of the consumer.Three newly employed staff have not yet signed a staff code of conduct document as required by the employment policy. Ensure staff received and signed the code of conduct document as part of the employment process. PA LowReporting Complete07/07/2022
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.(i). There were no current interventions documented in a care plan for the respite resident around a) management of a leg brace, b) the resident being non weight bearing, and c) management of surgical wounds. (ii). There were no current interventions documented for a rest home resident with recent weight loss. (i). – (ii). Ensure all care plans contain current interventions to reflect residents’ current needs and requirements. PA LowReporting Complete18/07/2022
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.There was no current medication chart signed by a doctor to safely administer the resident’s medication. Ensure all residents have a current medication chart signed by a doctor. PA ModerateReporting Complete18/07/2022
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.A corrective action plan following from issues raised during meetings (combined staff/quality and resident meetings) have not consistently been implemented. Ensure corrective action for all key areas requiring improvement are developed. PA LowReporting Complete18/07/2022
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.(i). Not all quality data including trends and analysis are not always evident as being communicated to staff. (ii). Internal audits results, non-conformities and corrective actions implemented have not consistently been evidenced as communicated to staff. (i)-(ii)Ensure that all components of the quality programme are discussed and evidenced as communicated to staff. PA LowReporting Complete18/07/2022
There is a document control system to manage the policies and procedures. This system shall ensure documents are approved, up to date, available to service providers and managed to preclude the use of obsolete documents.There is no evidence that staff have read and understood the policies. Ensure there is documented evidence that staff read and understood the policies. PA LowReporting Complete18/07/2022
A medication management system shall be implemented appropriate to the scope of the service.(i).Two of five eyedrops in current use were past the expiry date. (ii) Ten expired medications including creams and midazolam were available for current use. (i). Ensure all eyedrops in current use are discarded as per manufacturers guidelines. (ii) Ensure all expired medications are discarded. PA ModerateIn Progress
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).(i). Two dementia level care residents did not have interventions documented to manage recent weight loss and falls prevention strategies. (ii). One dementia level care resident did not have sufficient interventions documented to manage assessed challenging behaviours. (iii). One rest home resident did not have interventions documented in their long-term care plan to address assessed risks of bleeding, bruising, loss of limb function and diabetes, including frequency of blood glucose monitorin… (this text has been trimmed due to space limits).(i) –(iii). Ensure all care plans contain current interventions to reflect residents’ current needs and requirements. PA ModerateIn Progress
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).Three of three current wound plans in place did not consistently include fully completed assessments, or regular evaluations as per documented management plans. Ensure wound plans document assessments, a management plan, and regular evaluations. PA ModerateIn Progress
A process shall be implemented to identify, record, and communicate people’s medicinerelated allergies or sensitivities and respond appropriately to adverse events.The status of resident’s allergies was not recorded in ten of ten charts reviewed. Ensure the allergy status is documented on each resident’s medication chart. PA ModerateIn Progress
Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care.Quality data including corrective actions, trends and analysis are not consistently evidenced as being communicated to all staff. Ensure the quality system results are evidenced as communicated to all staff. PA ModerateReporting Complete22/05/2024

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: 08 August 2023

Audit type:Surveillance Audit

Audit date: 14 February 2022

Audit type:Certification Audit

Audit date: 15 November 2021

Audit type:Partial Provisional Audit

Audit date: 04 March 2021

Audit type:Provisional Audit

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