Kandahar Home

Profile & contact details

Premises details
Premises nameKandahar Home
Address 8 Roberts Road Lansdowne Masterton 5810
Total beds63
Service typesGeriatric, Medical, Rest home 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 2020
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: 20 October 2016

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
A process to measure achievement against the quality and risk management plan is implemented.There is no evidence of staff meetings being held in April, May and July 2016. Ensure that all scheduled staff meetings are held. PA LowReporting Complete19/06/2017
Advance directives that are made available to service providers are acted on where valid.Two advance care plans of dementia residents were evidenced to be signed by EPOAs. RNs interviewed lacked knowledge around informed consent and completion of advanced care plans. Ensure advance care plan/directives are signed by the resident assessed as competent to make an informed decision. Ensure RNs are trained around advanced directives/informed consent. PA LowReporting Complete19/06/2017
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).Monitoring of restraint when in use was evidenced to be documented as occurring two hourly and not hourly as prescribed in care plan. Ensure monitoring of the resident during the use of restraint is completed in the timeframe prescribed to minimise the risks around the use of restraint. PA LowReporting Complete19/06/2017
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 was no evidence of a completed incident form for a pressure injury that was identified on 21 July 2016. Ensure that incident forms are completed for all pressure injuries that occur. PA LowReporting Complete19/06/2017
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.There was no evidence of documented discussion around accidents/incidents, falls and infection trend analysis at staff meetings since the last audit in February 2016. Ensure that accidents/incidents, falls and infection trend analysis is discussed in staff meetings. PA LowReporting Complete18/07/2017
A process to measure achievement against the quality and risk management plan is implemented.There is no evidence of staff meetings being held in April, May and July 2016. Ensure that all scheduled staff meetings are held. PA LowReporting Complete19/06/2017
Advance directives that are made available to service providers are acted on where valid.Two advance care plans of dementia residents were evidenced to be signed by EPOAs. RNs interviewed lacked knowledge around informed consent and completion of advanced care plans. Ensure advance care plan/directives are signed by the resident assessed as competent to make an informed decision. Ensure RNs are trained around advanced directives/informed consent. PA LowReporting Complete19/06/2017
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).Monitoring of restraint when in use was evidenced to be documented as occurring two hourly and not hourly as prescribed in care plan. Ensure monitoring of the resident during the use of restraint is completed in the timeframe prescribed to minimise the risks around the use of restraint. PA LowReporting Complete19/06/2017
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 was no evidence of a completed incident form for a pressure injury that was identified on 21 July 2016. Ensure that incident forms are completed for all pressure injuries that occur. PA LowReporting Complete19/06/2017
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.There was no evidence of documented discussion around accidents/incidents, falls and infection trend analysis at staff meetings since the last audit in February 2016. Ensure that accidents/incidents, falls and infection trend analysis is discussed in staff meetings. PA LowReporting Complete18/07/2017

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: 20 October 2016

Audit type:Certification Audit

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

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