Coombrae Elderly Care

Profile & contact details

Premises details
Premises nameCoombrae Elderly Care
Address 34 North Street Feilding 4702
Total beds44
Service typesDementia care, Rest home care
Certification/licence details
Certification/licence namePresbyterian Support Central - Coombrae Elderly Care
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence19 December 2019
Certification period36 months
Provider details
Provider namePresbyterian Support Central
Street address 3-5 George Street Thorndon Wellington 6011
Post addressPO Box 12706 Thorndon Wellington 6144
Websitewww.psc.org.nz/

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: 22 September 2016

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Where progress is different from expected, the service responds by initiating changes to the service delivery plan.(i) One dementia resident’s file evidenced a recent change in continence needs with frequent episodes of incontinence documented in progress notes, however a follow-up assessment by an RN was not evidenced to have been completed or the care plan updated to reflect the change in health status. (ii) No short-term care plan was evidenced completed for a rest home resident who had returned from hospital following an incident, which required sutures to a large skin tear. (i) - (ii) Ensure care plans are updated or short-term care plans developed to address any acute changes in resident’s needs. PA LowReporting Complete21/02/2017
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.The clinical indicator data is collected but there is no documented evidence to identify this is then analysed, trended or evaluated. Ensure that all clinical indicator data is documented to reflect it is analysed, trended and evaluated. PA LowReporting Complete15/03/2017
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.(i) Two of five wounds did not evidence that dressing changes had been completed within the prescribed timeframe. (ii) Two of five wounds did not fully document the wound healing process with each dressing change. (iii) Neurological observations were not evidenced being consistently recorded as per policy for a dementia resident following two unwitnessed falls, one resulting in a laceration to the resident’s forehead. (i) Ensure wound dressings are completed within the prescribed timeframe; and (ii) Ensure that RN assessments document progress around wound healing with each dressing change. (iii) Ensure that neurological observations are recorded within the timeframes specified, as per policy for falls resulting in head injury or suspected head injury. PA LowReporting Complete15/03/2017
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.No corrective action plans were sighted or remedial actions evidenced where clinical indicator data, identified areas requiring improvement. The areas that were above an acceptable benchmark included falls, and behaviours. Ensure that corrective actions are documented and implemented where areas are identified requiring improvement. PA LowReporting Complete15/03/2017

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. 

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 reports

Audit date: 22 September 2016

Audit type:Certification Audit

Audit date: 03 August 2015

Audit type:Surveillance Audit

Audit date: 17 October 2013

Audit type:Certification Audit

Audit date: 24 October 2012

Audit type:Surveillance Audit

Audit date: 20 October 2011

Audit type:Certification Audit

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