Cornwall Resthome

Profile & contact details

Premises details
Premises nameCornwall Resthome
Address 3 Cornwall Street Masterton 5810
Total beds27
Service typesRest home care
Certification/licence details
Certification/licence nameKirsty Schofield
Current auditorThe DAA Group Limited
End date of current certificate/licence15 September 2018
Certification period36 months
Provider details
Provider nameKirsty Schofield
Street address3 Cornwall Street Masterton 5810

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 March 2017

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
The appointment of appropriate service providers to safely meet the needs of consumers.Five of the six files reviewed did not have reference checks documented, and four of the six files did not have evidence of police vetting. Provide evidence that all staff have reference checks and police vetting completed and documented. PA ModerateReporting Complete19/08/2015
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.Corrective actions do not consistently state timeframes and who is responsible for the implementation and monitoring and are not signed off as being completed. Provide evidence that corrective actions documented state the timeframe and who is responsible for implementing and monitoring, and are signed off once the action has been completed. PA LowReporting Complete19/08/2015
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.Resident care plans are not regularly evaluated. Those evaluations that have been completed do not comprehensively record resident progress towards planned outcomes. Comprehensive and timely evaluations of resident progress towards achieving desired outcomes are completed. PA ModerateReporting Complete19/08/2015
All records are legible and the name and designation of the service provider is identifiable.The names and designations of service providers making entries into the residents’ clinical records and/or completing clinical assessment documentation are not clearly identifiable and/or legible. The names and designations of services providers making entries into resident clinical records and/or completing clinical assessment documentation are legible. PA LowReporting Complete19/08/2015
Each episode of restraint is documented in sufficient detail to provide an accurate account of the indication for use, intervention, duration, its outcome, and shall include but is not limited to: (a) Details of the reasons for initiating the restraint, including the desired outcome; (b) Details of alternative interventions (including de-escalation techniques where applicable) that were attempted or considered prior to the use of restraint; (c) Details of any advocacy/support offered, provided o… (this text has been trimmed due to space limits).The restraint monitoring form does not allow staff to record monitoring times following observation of the resident. Provide evidence that the restraint monitoring form allows care staff to record when they observe the resident during restraint use. PA ModerateReporting Complete19/08/2015
Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer.The development of nursing care plans, the evaluation of those plans, and the completion of clinical assessments for new residents are not completed within required timeframes. Each stage of service provision is provided within timeframes that safely meet the needs of residents. PA ModerateReporting Complete19/08/2015
The needs, outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning.Ongoing assessments of clinical concerns, such as resident pain, are not completed as clinically indicated. Clinical assessments such as weight, blood pressure, temperature and pulse, are completed irregularly. The clinical status of residents is assessed / reassessed on a regular and as clinically indicated basis. PA ModerateReporting Complete19/08/2015
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.Quality improvement data is not being analysed and evaluated to identify trends. Quality improvement data is analysed to identify trends and evaluated and this information reported back to staff. PA ModerateReporting Complete19/08/2015
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Not all staff have attended challenging behaviour education and clinical staff files do not evidence restraint competencies. Provide evidence that all staff have received challenging behaviour training and that all clinical staff have restraint competency assessments completed and that these assessments are ongoing. PA ModerateReporting Complete02/12/2015
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.Documentation was unable to evidence resident care plans were being regularly evaluated. Those evaluations that have been completed do not comprehensively record resident progress towards planned outcomes. Comprehensive and timely evaluation of resident progress towards desired outcomes are documented. PA ModerateIn Progress
The needs, outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning.Ongoing assessments of clinical concerns such as pain, falls, medication changes, behaviour changes are not completed. The clinical status of residents is assessed/reassessed on a regular basis as clinically indicated. PA ModerateIn Progress
All records are legible and the name and designation of the service provider is identifiable.The names and designations of service providers making entries into the residents, clinical records are not clearly identifiable and/or legible. The names and designations of service providers making entries into residents’ clinical records are identifiable and legible PA LowReporting Complete08/09/2017

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 March 2017

Audit type:Surveillance Audit

Audit date: 24 June 2015

Audit type:Certification Audit

Audit date: 30 January 2014

Audit type:Surveillance Audit

Audit date: 18 July 2012

Audit type:Certification Audit

Audit date: 22 February 2011

Audit type:Surveillance Audit

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