Profile & contact details
|Premises name||Colwyn House|
|Address||707 Duke Street Mahora Hastings 4120|
|Service types||Dementia care, Psychogeriatric, Geriatric, Medical|
|Certification/licence name||Heritage Lifecare Limited - Colwyn House|
|Current auditor||The DAA Group Limited|
|End date of current certificate/licence||01 April 2021|
|Certification period||Other months|
|Provider name||Heritage Lifecare Limited|
|Street address||Level 2 111 Johnsonville Road Johnsonville Wellington 6037|
|Post address||PO Box 13223 Johnsonville Wellington 6440|
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: 17 September 2019
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include: (a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk; (b) A process that addresses/treats the risks associated with service provision is developed and im… (this text has been trimmed due to space limits).||A hazard register for Colwyn House could not be located.||Ensure Colwyn house hazards are identified, and mitigation strategies implemented and monitored over time.||PA Low||In Progress|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Corrective action plans are not consistently developed when areas for improvement are identified including in response to complaints and internal audit findings.||Ensure corrective action plans are consistently developed when areas for improvements are identified and are implemented and monitored for effectiveness in a timely manner.||PA Moderate||Reporting Complete||13/08/2020|
|The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.||The essential notification records held at Colwyn House is incomplete. Section 31 documents detailing the circumstances of reported events are not present for some reported events. Records were not available to demonstrate that the death of a resident in June 2019, reported to the Coroner has been reported as an essential notification.||Ensure complete records are available in Colwyn House to demonstrate that all applicable events are being reported as essential notifications.||PA Moderate||Reporting Complete||13/08/2020|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||The complaints register does not include details of the complaint received via the Health and Disability Commissions Office on 27 August 2019. Family members stated there is insufficient furniture in the lounge and dining rooms for visitors to use.||Ensure the complaints register includes all complaints received, and actions undertaken. Ensure sufficient furniture is available for residents and their visitors.||PA Low||Reporting Complete||13/08/2020|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||There are a range of clinical indicators linked to the events/incident reporting process. Records are not available to demonstrate that detailed analysis of these events, including themes and trends, has occurred for the period April 2019 to July 2019 inclusive. Actions taken in response to clinical indicator data was not available for review except for March and August 2019.||Ensure clinical indicator data is reviewed and analysed in a timely manner, with appropriate interventions undertaken based on findings.||PA Moderate||Reporting Complete||13/08/2020|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||Three care staff who have been employed more than eighteen months have not completed an industry approved dementia care qualification. All family members interviewed spoke highly of staff but noted that on occasions there are insufficient staff available for the provision of resident care. There is a high resident falls rate.||All care staff complete industry approved dementia qualifications within eighteen months of employment. Review staffing to ensure staffing and skill mix facilitates safe service delivery and a reduction in falls.||PA Moderate||Reporting Complete||13/08/2020|
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: 17 September 2019
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Provisional Audit