Profile & contact details
|Premises name||Lifecare Cambridge|
|Address||86 King Street Cambridge 3434|
|Service types||Rest home care, Geriatric, Medical|
|Certification/licence name||Lifecare Cambridge Limited - Lifecare Cambridge|
|Current auditor||The DAA Group Limited|
|End date of current certificate/licence||22 September 2019|
|Certification period||36 months|
|Provider name||Lifecare Cambridge Limited|
|Street address||86 King Street Cambridge 3434|
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: 11 July 2016
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Key components of service delivery shall be explicitly linked to the quality management system.||There is no clearly described or implemented quality management system. Apart from the audits and surveys conducted by domestic services there is no regular and transparent monitoring of service delivery or stated measurements for assessing the quality of services.||Document and implement a quality management system which reliably measures and monitors service delivery to identify where improvements are required.||PA Moderate||Reporting Complete||11/04/2017|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Quality improvement data is not identified in the quality policy or plan. Information is being gathered (for example collation of event reports) but this is not being rigorously or systematically analysed to determine trends and identify where and what improvements are required. Staff attest to actions being taken but this is not recorded nor is there any evaluation to show that actions have resulted in remedying the problems.||Describe what is considered to be quality improvement data, gather relevant information for analysis to determine cause and effect, initiate remedial actions where required and evaluate the effectiveness of any actions taken.||PA Moderate||Reporting Complete||11/04/2017|
|A process to measure achievement against the quality and risk management plan is implemented.||There are no clearly described quality objectives or indicators and no implemented processes for measuring achievement against the quality and risk plan.||Develop quality objectives that are measurable and implement systems for monitoring and testing these...||PA Moderate||Reporting Complete||11/04/2017|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||There is a lack of planning and coordination in determining the most effective corrective actions, ensuring actions are implemented and evaluating whether or not the actions have had the desired effect.||Ensure that where improvements are required, the actions required to remedy these are documented, that the actions are monitored to ensure these occur and that the effectiveness of the actions is evaluated to check that the issues are resolved.||PA Moderate||Reporting Complete||11/04/2017|
|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 is no evidence that incidents are used as opportunities for improvement or to identify and manage risk. The incident data is not adequately analysed or compared to identify areas of risk, where improvements are needed or if improvements or negative trends have occurred.||Demonstrate who incident and accident data is used to make service improvements and identify and manage risk.||PA Moderate||Reporting Complete||11/04/2017|
|Information is entered into the consumer information management system in an accurate and timely manner, appropriate to the service type and setting.||The sample of files reviewed did not contain unique identifiers on progress notes, short term care plans, consents and all snapshot activity forms.||Ensure that all documents related to residents contain uniquely identifying information (for example, NHI and full name or date of birth.||PA Low||Reporting Complete||11/04/2017|
|Results of surveillance, conclusions, and specific recommendations to assist in achieving infection reduction and prevention outcomes are acted upon, evaluated, and reported to relevant personnel and management in a timely manner.||Infection data is not being collected accurately and there is no comparison of data to determine trends.||Develop and implement a systematic method for accurately collecting and comparing infection information.||PA Low||Reporting Complete||11/04/2017|
|The organisation has a quality and risk management system which is understood and implemented by service providers.||The service provider has still not understood or implemented a robust quality and risk management system.||Develop and implement a quality and risk management system which effectively monitors and measures service outcomes and ensure all staff understand this.||PA Moderate||Reporting Complete||11/04/2017|
|Infection control education is provided by a suitably qualified person who maintains their knowledge of current practice.||The infection control nurse has not completed formal infection control education to maintain their knowledge of current practice.||The infection control nurse complete infection control education.||PA Low||Reporting Complete||21/06/2017|
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.
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 reportsAudit date: 11 July 2016
Audit type:Certification Audit
Audit type:Partial Provisional Audit; Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit