Woodfall Lodge Home and Hospital
Profile & contact details
|Premises name||Woodfall Lodge Home and Hospital|
|Address||4 Bowen Street Feilding 4702|
|Service types||Rest home care, Geriatric|
|Certification/licence name||Experion Care NZ Limited - Woodfall Lodge Home and Hospital|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||17 September 2024|
|Certification period||36 months|
|Provider name||Experion Care NZ Limited|
|Street address||283 Kennedy Road Onekawa Napier 4112|
|Post address||283 Kennedy Road Pirimai 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: 01 July 2021
|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) Not all registered nurses have a current first aid certificate.’ (ii) There is no documented evidence the CNM has received recent infection prevention and control (IPC) education.||(i) Provide evidence that all RNs have a current first aid certificate. (ii) Provide evidence the CNM has received recent training for the IPC coordinator’s role.||PA Low||Reporting Complete||19/11/2021|
|The facilitation of safe self-administration of medicines by consumers where appropriate.||Self-administration competency for one resident was not completed three monthly as per medication policy requirements, last reviewed 11 November 2020.||Complete self-administration competencies for residents who self-administers medicines in a timely manner||PA Moderate||Reporting Complete||07/12/2021|
|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.||Six-monthly controlled drugs stock take was not consistently completed as per policy requirements.||Ensure six monthly controlled drugs stock take are completed to comply with policy requirements and current legislation.||PA Moderate||Reporting Complete||07/12/2021|
|Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.||The four weekly seasonal menu, has not been approved by a dietitian since November 2018 as per previous dietitian report.||Provide evidence of current menu review by a registered dietitian.||PA Low||Reporting Complete||21/12/2021|
|Consumers have a right to full and frank information and open disclosure from service providers.||Family and resident interviews reported: (i) resident and family members meetings are inconsistently held. Meeting minutes evidenced only one meeting dated March 2021. (ii) The facility newsletter is no longer completed. (ii) The resident and relatives survey was completed 28th June 2021 and still requires collation and reporting. However, there is no documented evidence a survey was completed in 2020.||(i) Provide evidence that resident and family meetings are held regularly. (ii) A facility newsletter is completed. (iii) the resident and family survey is collated, analysed, and reported through to appropriate personal.||PA Low||Reporting Complete||21/12/2021|
|Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is undertaken by suitably qualified and/or experienced service providers who are competent to perform the function.||(i)There were nine (9) overdue interRAI assessments. (ii) Four (4) activity care plans sampled were not developed in conjunction with interRAI assessments.||(i)Ensure all interRAI assessments are completed within timeframes that safely meet the needs of the residents and ARCC contract requirements. (ii) Ensure activity care plans are developed following outcomes from interRAI assessments.||PA Moderate||Reporting Complete||02/02/2022|
|The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.||(i) Chipped formica on the bench between the kitchen and dining area in the Makino wing. (ii) Refurbishment in the kitchen including installation of tiles in the wet areas has not been completed. (iii) Bathroom vinyl that is worn and not adhered to the floor or wall surfaces, in the Rimu wing. (iiii) Worn and stained carpet throughout the facility (iiii) internal doors in the Makino wing were noted to have significant damage on the outside coverings.||Ensure all physical environmental surfaces are presented in a condition that meets infection prevention and control standards.||PA Low||Reporting Complete||05/05/2022|
|An appropriate 'call system' is available to summon assistance when required.||Each current resident has a call bell and cord that is functional. However, there are insufficient cords to ensure each of the facility resident room, dining areas and lounges has a functional call bell. Discussion with the GM in relation to the call bell system noted two older systems and the cords were not readily available, and this required juggling of residents’ rooms to enable each resident to have a call bell that is accessible and within reach and available. Handheld bells are used if re… (this text has been trimmed due to space limits).||Ensure each resident area has a call bell and cord that is functional.||PA Low||Reporting Complete||30/05/2022|
|Service providers shall engage with people receiving services to assess and develop their individual care or support plan in a timely manner. Whānau shall be involved when the person receiving services requests this.||(i). InterRAI assessments were not within timeframes for one hospital level resident and one rest home level resident; (ii) Two files (one hospital and one rest home) reviewed did not have long-term care plans completed within 21 days.||(i) Ensure interRAI assessments are completed within contractual timeframes; (ii) Ensure long-term care plans have been completed within 21 days.||PA Moderate||In Progress|
|Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care.||(i). Staff meetings have not been documented as occurring as per the meeting schedule. (ii). Internal audits scheduled for February, March, June, and July 2022 were not all documented as completed. These audits included (but not limited to): infection control and medication (March); clinical files (March); resident pain management (May); resident rights (June); and Covid preparedness (July). (iii). Audits that had been completed for June, August, and September 2022, included an action plan but n… (this text has been trimmed due to space limits).||(i)-(iii). Ensure internal audits are fully implemented and documentation reflects implementation of action plans.||PA Moderate||In Progress|
|Meaningful activities shall be planned and facilitated to develop and enhance people’s strengths, skills, resources, and interests, and shall be responsive to their identity.||(i). There were no individualised activity plans in the five resident files reviewed. (ii). A review of activities provided over a recent two-week period, identified that 7 of the 18 planned activities had not taken place. There was no documented evidence that an alternative activity was provided.||(i)-(ii). Ensure that residents have an individualised activity plan documented and activities are provided.||PA Moderate||In Progress|
|Service providers shall ensure there is a system to identify, plan, facilitate, and record ongoing learning and development for health care and support workers so that they can provide high-quality safe services.||There was little evidence of training being provided in 2022. There has been no documented training and competency for mandatory training including: cultural training, medication competencies and infection control.||Ensure staff have completed the training and competencies relevant to their role.||PA Moderate||In Progress|
|Service providers ensure competent health care and support workers manage medication including: receiving, storage, administration, monitoring, safe disposal, or returning to pharmacy.||Annual medication competencies and medication training has not been completed for staff administering medications in the last year.||Ensure all staff who administer medications have an up-to-date competency and receive annual medication training.||PA Moderate||In Progress|
|Planned review of a person’s care or support plan shall: (a) Be undertaken at defined intervals in collaboration with the person and whānau, together with wider service providers; (b) Include the use of a range of outcome measurements; (c) Record the degree of achievement against the person’s agreed goals and aspiration as well as whānau goals and aspirations; (d) Identify changes to the person’s care or support plan, which are agreed collaboratively through the ongoing re-assessment and review … (this text has been trimmed due to space limits).||One hospital level and one rest home level resident’s care plan did not have six-monthly documented evaluations of care.||Ensure the process of evaluation of care plans is implemented.||PA Moderate||In Progress|
|The nutritional value of menus shall be reviewed by appropriately qualified personnel such as dietitians.||The menu has not been approved by a registered dietitian.||Ensure the menu is reviewed and approved by a registered dietitian.||PA Moderate||In Progress|
Guide to table
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: 01 July 2021
Audit type:Certification Audit
- Woodfall Lodge Home and Hospital - Jul 2021 (docx, 46.17 KB)
- Woodfall Lodge Home and Hospital - Jul 2021 (pdf, 178.21 KB)
Audit type:Provisional Audit