Kandahar Court

Profile & contact details

Premises details
Premises nameKandahar Court
Address 2/4 Colombo Road Lansdowne Masterton 5810
Total beds37
Service typesDementia care
Certification/licence details
Certification/licence namePresbyterian Support Central - Kandahar
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence25 January 2017
Certification period24 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: 18 February 2016

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate 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) Residents who are assessed as competent to self-medicate (five hospital residents) are given their individual medicine doses by the registered nurse. Residents are left with their medications to take at a time convenient to them. The RN then signs that the resident has taken the medications, however, the nurse has not witnessed the ingestion of the medicines. This practice does not align with facility policy for self- administration; ii) residents with insulin are given the correct doses a… (this text has been trimmed due to space limits).i) ensure correct and safe procedure is followed when administering medications as per facility policy and medicine care guidelines 2011; ii) document insulin doses on separate signing sheets. iii) ensure antipsychotic injections are given as prescribed. PA ModerateReporting Complete08/04/2015
In assessing whether restraint will be used, appropriate factors are taken into consideration by a suitably skilled service provider. This shall include but is not limited to: (a) Any risks related to the use of restraint; (b) Any underlying causes for the relevant behaviour or condition if known; (c) Existing advance directives the consumer may have made; (d) Whether the consumer has been restrained in the past and, if so, an evaluation of these episodes; (e) Any history of trauma or abuse, whi… (this text has been trimmed due to space limits).The restraint care plans for four hospital level residents do not include the risks associated with the restraint and the cares and comfort measures required to be implemented when restraint is in use. Ensure that all restraint care plans detail the individual resident’s risks associated with the use of restraint and also details the cares and comfort measures required while restraint is in use. PA LowReporting Complete09/06/2015
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).Progress notes reviewed for four hospital and two dementia residents using restraint do not evidence that monitoring has occurred as per the enabler policy and procedures. There is insufficient detail to provide an accurate account of the reasons for use, duration, monitoring and cares provided. Provide evidence that monitoring of restraint has occurred at the frequency recorded in policy and procedures and individual care plans PA ModerateReporting Complete09/06/2015
The use of enablers shall be voluntary and the least restrictive option to meet the needs of the consumer with the intention of promoting or maintaining consumer independence and safety.The service has assessed and classified all residents with restraint as ‘enabler’s. This does not align with the 2008 restraint minimisation and safe practice standards. The decision for the use of ‘enablers’ has not been a voluntary decision made by the resident or activated EPOA. The reasons for use of ‘enablers’ for five hospital and two dementia residents constitutes restraint. The policy requires review (as per finding in #1.2.3.3) to align with the current standards and best practice. … (this text has been trimmed due to space limits).Ensure that all residents with restraint are classified as such to align with current standards and best practice. PA LowReporting Complete09/06/2015
The service develops and implements policies and procedures that are aligned with current good practice and service delivery, meet the requirements of legislation, and are reviewed at regular intervals as defined by policy.The policy for the use of enablers does not align with the restraint minimisation and safe practice for the 2008 Health and Disability Sector Standards. The medication policy around timeframes for staff for medication competencies does not align with the Ministry of Health medication guidelines. The protocol around head injury neurological observations does not meet current good practice. Ensure policies and procedures align with current good practice and meet the requirements of legislation. PA LowReporting Complete09/06/2015
The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk. There is no evidence of neurological observations for three hospital residents and one dementia care resident following falls with head injury. Ensure neurological observations are commenced for all falls with head injury. PA LowReporting Complete09/06/2015
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.i) One hospital resident who was transferred from the dementia unit to hospital level care had a long term care plan written prior to admission. No new assessments were conducted and a new care plan was not written until two months after admission; ii) one rest home respite resident (with frequent prior respite admissions) did not have new risk assessments conducted for the current admission. The service was utilising a previous care plan written in May 2014. The comprehensive assessment was … (this text has been trimmed due to space limits).Ensure that all assessments are completed and reviewed as per contractual and resident requirements PA LowReporting Complete09/06/2015
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.i) The care plan evaluation for one hospital resident completed in January 2016 documented no weight loss over the review period, however the weight monitoring recorded from November to January showed a 3kg weight loss. ii) Two of five files sampled did not evidence that the three monthly GP reviews had been consistently completed within the required time frames. i) Ensure a review of the long term care plan includes a review of all relevant assessments completed ii) Ensure that the GP reviews the resident at least three monthly PA LowIn Progress
A process to measure achievement against the quality and risk management plan is implemented.Eden and registered nurses meetings are scheduled to be monthly. There is no evidence of Eden meetings being held for July to December 2015. Eden meetings were cancelled for January, February and May 2015. There was no evidence of a registered nurses meeting for December 2015. Ensure that all scheduled meetings are held. PA LowReporting Complete17/06/2016
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.i) The nursing assessments and long term care plan were not updated following a change in care level for one respite resident transferred to rest home care and one rest home resident transferred to hospital care. ii) One of two rest home resident files reviewed documented the resident was admitted in October 2015 but was not commenced on the interRAI until February 2016. The second rest home file reviewed documented the resident was admitted in October 2015 and had not been commenced on the i… (this text has been trimmed due to space limits).i) Ensure that nursing assessments are reviewed and the long term care plan is updated following a change in care level. ii) Ensure that all interRAI assessments are completed and reviewed according to the contractual requirements PA ModerateReporting Complete17/06/2016
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.i)Fifteen of fifteen wound care plans reviewed did not have a) an initial or ongoing wound assessments documented with each dressing change, b) specific interventions documented for management of the wound (frequency of dressing change, care of the wound bed) and c) evaluations of the wound management plan; ii) Long term and short term care plan interventions did not fully describe the care requirements for two hospital residents with weight loss, one dementia resident (tracer) with a change i… (this text has been trimmed due to space limits).i) Ensure that wound care plans are fully documented and wound care documentation complies fully with the PSC wound management policy; ii) Ensure that long term and short term care plans include all interventions required for residents noted in the progress notes are transferred to the care plan; And iii) ensure that all monitoring is conducted and recorded as per care plan instructions. PA ModerateReporting Complete17/06/2016
The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk.Five of six residents who suffered an unwitnessed fall did not have neurological assessments fully documented. Ensure neurological observations are commenced and completed for all falls with possible or suspected head injury. PA ModerateReporting Complete25/07/2016
Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.i) Three of five resident files reviewed did not have an activity/recreational assessment documented or an activity/recreational care plan completed. ii) One of five files reviewed did not have the activity/recreational care plan reviewed in conjunction with the long term care plan. i) Ensure all residents have a documented activity/recreational care plan ii) Ensure that all activity/recreational care plans are reviewed in conjunction with the review of the long term care plan PA LowReporting Complete25/07/2016
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.One hospital resident was charted weekly Overstin cream and monthly Calciform. Both these medications were being signed as given for on the regular blister packaged signing sheet with each regular blister pack medication time. Ensure that all weekly and monthly medication has a separate signing sheet PA LowReporting Complete25/07/2016
Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.i) Six out of ten medication charts reviewed did not have indications for use charted for as required medication. ii) One of ten medication charts reviewed had an indication for use written by the registered nurse that was not signed by the GP Ensure that all as required medication prescribing meets all contractual and legislative requirements. PA LowReporting Complete25/07/2016
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) Residents who are assessed as competent to self-medicate (five hospital residents) are given their individual medicine doses by the registered nurse. Residents are left with their medications to take at a time convenient to them. The RN then signs that the resident has taken the medications, however, the nurse has not witnessed the ingestion of the medicines. This practice does not align with facility policy for self- administration; ii) residents with insulin are given the correct doses a… (this text has been trimmed due to space limits).i) ensure correct and safe procedure is followed when administering medications as per facility policy and medicine care guidelines 2011; ii) document insulin doses on separate signing sheets. iii) ensure antipsychotic injections are given as prescribed. PA ModerateReporting Complete08/04/2015
In assessing whether restraint will be used, appropriate factors are taken into consideration by a suitably skilled service provider. This shall include but is not limited to: (a) Any risks related to the use of restraint; (b) Any underlying causes for the relevant behaviour or condition if known; (c) Existing advance directives the consumer may have made; (d) Whether the consumer has been restrained in the past and, if so, an evaluation of these episodes; (e) Any history of trauma or abuse, whi… (this text has been trimmed due to space limits).The restraint care plans for four hospital level residents do not include the risks associated with the restraint and the cares and comfort measures required to be implemented when restraint is in use. Ensure that all restraint care plans detail the individual resident’s risks associated with the use of restraint and also details the cares and comfort measures required while restraint is in use. PA LowReporting Complete09/06/2015
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).Progress notes reviewed for four hospital and two dementia residents using restraint do not evidence that monitoring has occurred as per the enabler policy and procedures. There is insufficient detail to provide an accurate account of the reasons for use, duration, monitoring and cares provided. Provide evidence that monitoring of restraint has occurred at the frequency recorded in policy and procedures and individual care plans PA ModerateReporting Complete09/06/2015
The use of enablers shall be voluntary and the least restrictive option to meet the needs of the consumer with the intention of promoting or maintaining consumer independence and safety.The service has assessed and classified all residents with restraint as ‘enabler’s. This does not align with the 2008 restraint minimisation and safe practice standards. The decision for the use of ‘enablers’ has not been a voluntary decision made by the resident or activated EPOA. The reasons for use of ‘enablers’ for five hospital and two dementia residents constitutes restraint. The policy requires review (as per finding in #1.2.3.3) to align with the current standards and best practice. … (this text has been trimmed due to space limits).Ensure that all residents with restraint are classified as such to align with current standards and best practice. PA LowReporting Complete09/06/2015
The service develops and implements policies and procedures that are aligned with current good practice and service delivery, meet the requirements of legislation, and are reviewed at regular intervals as defined by policy.The policy for the use of enablers does not align with the restraint minimisation and safe practice for the 2008 Health and Disability Sector Standards. The medication policy around timeframes for staff for medication competencies does not align with the Ministry of Health medication guidelines. The protocol around head injury neurological observations does not meet current good practice. Ensure policies and procedures align with current good practice and meet the requirements of legislation. PA LowReporting Complete09/06/2015
The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk. There is no evidence of neurological observations for three hospital residents and one dementia care resident following falls with head injury. Ensure neurological observations are commenced for all falls with head injury. PA LowReporting Complete09/06/2015
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.i) One hospital resident who was transferred from the dementia unit to hospital level care had a long term care plan written prior to admission. No new assessments were conducted and a new care plan was not written until two months after admission; ii) one rest home respite resident (with frequent prior respite admissions) did not have new risk assessments conducted for the current admission. The service was utilising a previous care plan written in May 2014. The comprehensive assessment was … (this text has been trimmed due to space limits).Ensure that all assessments are completed and reviewed as per contractual and resident requirements PA LowReporting Complete09/06/2015
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.i) The care plan evaluation for one hospital resident completed in January 2016 documented no weight loss over the review period, however the weight monitoring recorded from November to January showed a 3kg weight loss. ii) Two of five files sampled did not evidence that the three monthly GP reviews had been consistently completed within the required time frames. i) Ensure a review of the long term care plan includes a review of all relevant assessments completed ii) Ensure that the GP reviews the resident at least three monthly PA LowIn Progress
A process to measure achievement against the quality and risk management plan is implemented.Eden and registered nurses meetings are scheduled to be monthly. There is no evidence of Eden meetings being held for July to December 2015. Eden meetings were cancelled for January, February and May 2015. There was no evidence of a registered nurses meeting for December 2015. Ensure that all scheduled meetings are held. PA LowReporting Complete17/06/2016
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.i) The nursing assessments and long term care plan were not updated following a change in care level for one respite resident transferred to rest home care and one rest home resident transferred to hospital care. ii) One of two rest home resident files reviewed documented the resident was admitted in October 2015 but was not commenced on the interRAI until February 2016. The second rest home file reviewed documented the resident was admitted in October 2015 and had not been commenced on the i… (this text has been trimmed due to space limits).i) Ensure that nursing assessments are reviewed and the long term care plan is updated following a change in care level. ii) Ensure that all interRAI assessments are completed and reviewed according to the contractual requirements PA ModerateReporting Complete17/06/2016
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.i)Fifteen of fifteen wound care plans reviewed did not have a) an initial or ongoing wound assessments documented with each dressing change, b) specific interventions documented for management of the wound (frequency of dressing change, care of the wound bed) and c) evaluations of the wound management plan; ii) Long term and short term care plan interventions did not fully describe the care requirements for two hospital residents with weight loss, one dementia resident (tracer) with a change i… (this text has been trimmed due to space limits).i) Ensure that wound care plans are fully documented and wound care documentation complies fully with the PSC wound management policy; ii) Ensure that long term and short term care plans include all interventions required for residents noted in the progress notes are transferred to the care plan; And iii) ensure that all monitoring is conducted and recorded as per care plan instructions. PA ModerateReporting Complete17/06/2016
The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk.Five of six residents who suffered an unwitnessed fall did not have neurological assessments fully documented. Ensure neurological observations are commenced and completed for all falls with possible or suspected head injury. PA ModerateReporting Complete25/07/2016
Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.i) Three of five resident files reviewed did not have an activity/recreational assessment documented or an activity/recreational care plan completed. ii) One of five files reviewed did not have the activity/recreational care plan reviewed in conjunction with the long term care plan. i) Ensure all residents have a documented activity/recreational care plan ii) Ensure that all activity/recreational care plans are reviewed in conjunction with the review of the long term care plan PA LowReporting Complete25/07/2016
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.One hospital resident was charted weekly Overstin cream and monthly Calciform. Both these medications were being signed as given for on the regular blister packaged signing sheet with each regular blister pack medication time. Ensure that all weekly and monthly medication has a separate signing sheet PA LowReporting Complete25/07/2016
Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.i) Six out of ten medication charts reviewed did not have indications for use charted for as required medication. ii) One of ten medication charts reviewed had an indication for use written by the registered nurse that was not signed by the GP Ensure that all as required medication prescribing meets all contractual and legislative requirements. PA LowReporting Complete25/07/2016

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: 18 February 2016

Audit type:Surveillance Audit

Audit date: 24 November 2014

Audit type:Certification Audit

Audit date: 17 September 2013

Audit type:Surveillance Audit

Audit date: 23 November 2011

Audit type:Certification Audit

Audit date: 26 January 2011

Audit type:Surveillance Audit

Audit date: 14 December 2009

Audit type:Certification Audit

Back to top