Profile & contact details
|Premises name||Westmar 2021|
|Address||12 Kimberley Road Darfield 7510|
|Service types||Dementia care, Rest home care|
|Certification/licence name||Westmar 2021 Limited - Westmar 2021|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||30 April 2025|
|Certification period||36 months|
|Provider name||Westmar 2021 Limited|
|Street address||12 Kimberley Road Darfield 7510|
|Post address||12 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: 14 February 2022
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date 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 Low||Reporting Complete||07/07/2022|
|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 Low||Reporting Complete||07/07/2022|
|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 Low||Reporting Complete||07/07/2022|
|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 Low||Reporting Complete||07/07/2022|
|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 Low||Reporting Complete||18/07/2022|
|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 Moderate||Reporting Complete||18/07/2022|
|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 Low||Reporting Complete||18/07/2022|
|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 Low||Reporting Complete||18/07/2022|
|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 Low||Reporting Complete||18/07/2022|
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.
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 reportsAudit date: 14 February 2022
Audit type:Certification Audit
Audit type:Partial Provisional Audit
Audit type:Provisional Audit