Profile & contact details
|Premises name||Whalan Lodge|
|Address||5 Diggers Gully Road Kurow 9435|
|Service types||Rest home care|
|Certification/licence name||The Whalan Lodge Trust - Whalan Lodge|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||10 July 2020|
|Certification period||24 months|
|Provider name||The Whalan Lodge Trust|
|Street address||5 Diggers Gulley Road Kurow 9435|
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: 15 May 2019
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|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.||i) Medication fridge temperatures are not documented as reviewed. ii) Weekly controlled drug checks are not documented as occurring. iii) For six of ten medication files sampled, GP three monthly reviews had not been documented as completed. iv) The prescription on four of ten medication charts sampled had one signature and a bracket to imply the signature applied to all dates and/or medicines prescribed. v) Four of ten medication charts did not have indications for use documented for ‘a… (this text has been trimmed due to space limits).||i) Ensure medication fridge temperatures are taken and recorded regularly. ii) Ensure weekly controlled drug checks occur. iii) Ensure three monthly GP medication reviews occur and are documented. iv) Ensure each medication on a chart has an individual signature and date. v) Ensure indications for use are documented by the prescriber for all ‘as required’ medications. vi) Ensure allergies are documented for every resident. vii) Ensure warfarin is managed safely and a doctor signs fo… (this text has been trimmed due to space limits).||PA Moderate||Reporting Complete||19/02/2019|
|The appointment of appropriate service providers to safely meet the needs of consumers.||Five staff files were reviewed, four of five files did not have documented evidence of completed orientation checklists, two of five did not include an up-to-date annual performance appraisal and four of five did not have reference checks completed.||Ensure that all staff files include completed orientation checklists, annual performance appraisals and reference checks.||PA Low||Reporting Complete||19/02/2019|
|Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include: (a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk; (b) A process that addresses/treats the risks associated with service provision is developed and im… (this text has been trimmed due to space limits).||A documented hazard register for the facility that includes identified on-going hazards and new hazards could not be located.||Ensure that there is a documented hazard register in place and this is reviewed regularly.||PA Moderate||Reporting Complete||19/02/2019|
|Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome.||Five of five care plan evaluations do not consistently record the degree of achievement to the intervention provided and progress towards meeting the desired outcomes.||Ensure care plan evaluations did not document progress toward goals.||PA Low||Reporting Complete||19/02/2019|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||Opened dry goods and cereals were not stored in sealed containers. Decanted food was not dated.||Ensure that food storage complies with legislation.||PA Low||Reporting Complete||19/02/2019|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Five of five resident files sampled did not document interventions for all identified needs. Examples included diabetes management, UTI, warfarin management, pain management behaviour and falls management.||Ensure care plans have documented interventions for all identified needs.||PA Moderate||Reporting Complete||19/02/2019|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||i) There was no documented evidence of internal audits being completed as per the required schedule for 34 of 44 internal audits for 2017 and 10 of 21 audits for 2018 year-to-date. ii) Corrective actions required for internal audits that are not compliant, have not been fully completed or signed off.||i) Ensure that all internal audits are completed as per the required schedule. ii) Ensure that corrective actions required for internal audits that are not compliant, are fully completed and signed off.||PA Low||Reporting Complete||19/02/2019|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||i) Three of five resident files sampled did not have the effectiveness of ‘as required’ pain relief documented. ii) One resident that has behaviours that challenge did not have any behaviour monitoring and two residents with a potential knock to the head did not have neuro observations taken.||i) Ensure the effectiveness of ‘as required’ medications are documented. ii) Ensure that residents with challenging behaviours have these monitored and a potential hit to the head have neuro observations taken.||PA Moderate||Reporting Complete||19/02/2019|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||(i) There is no staff member designated to provide activities and interviews with residents and families indicated neutrality or discontent with the activities programme. (ii) Two of five resident files sampled did not have an activities assessment or plan documented. (iii) Three of three residents with activities plans had not had these reviewed for more than 12 months.||(i) Ensure staff with hours dedicated to activities develop and implement an activity plan that meets the needs and interests of the residents. (ii) – (iii) Ensure all residents have an activities assessment and plan and this is reviewed at least 6-monthly with the care plan review||PA Moderate||Reporting Complete||19/02/2019|
|Consumers have a right to full and frank information and open disclosure from service providers.||Ten accident/incident forms were reviewed in total. Ten of ten incident forms did not have documented evidence of notification to next of kin.||Ensure that documentation reflects that next of kin are notified of any resident incidents/accidents.||PA Low||Reporting Complete||19/02/2019|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||i) There was no documented evidence of eight hours annual training being completed for all staff in 2017. ii) Not all compulsory education has been completed within the required two-year period. Education not completed includes; abuse and neglect, cultural safety, code of rights, sexuality/intimacy, spirituality/counselling, complaints/open disclosure, nutrition/hydration, and privacy/dignity.||i) Ensure that there is eight hours annual training being completed for all staff. ii) Ensure that the annual education planner is fully implemented, and education is provided to cover all contractual and legal requirements.||PA Low||Reporting Complete||19/02/2019|
|All buildings, plant, and equipment comply with legislation.||There was no evidence of monitoring or recording of hot water temperatures.||Ensure hot water temperatures are monitored and recorded regularly.||PA Low||Reporting Complete||14/06/2019|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||(i) Three residents with unintentional weight loss had no interventions documented around this, either in a short-term care plan or the long-term care plan. (ii) One resident on warfarin had no risks or side effects documented in the long-term care plan. (iii) One resident with a chronic wound did not have interventions to support the wound, or risks and reporting associated with a wound documented in the long-term care plan or a short-term care plan.||(i)-(iii) Ensure all care plans and short-term care plans are reflective of current resident need.||PA Moderate||Reporting Complete||09/10/2019|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||Behaviour monitoring charts and care plans do not identify triggers or a description of the behaviours.||Ensure behaviour monitoring forms describe the whole episode of challenging behaviour to aid identification of possible triggers and interventions in the care plan.||PA Moderate||Reporting Complete||09/10/2019|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||i) Two of five resident files reviewed did not have completed activities care plans. ii) Five of five residents’ files did not have activities care plans evaluated at least six monthly.||Ensure all residents have completed care plans and care plans are evaluated at least six monthly.||PA Moderate||Reporting Complete||09/10/2019|
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: 15 May 2019
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Provisional Audit