Colwyn House

Profile & contact details

Premises details
Premises nameColwyn House
Address 707 Duke Street Mahora Hastings 4120
Total beds73
Service typesPsychogeriatric, Geriatric, Medical, Dementia care
Certification/licence details
Certification/licence nameHeritage Lifecare Limited - Colwyn House
Current auditorThe DAA Group Limited
End date of current certificate/licence01 April 2024
Certification period36 months
Provider details
Provider nameHeritage Lifecare Limited
Street address 16 Johnsonville Road Johnsonville Wellington 6037
Post addressPO 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: 27 January 2021

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
A process to measure achievement against the quality and risk management plan is implemented.Internal audits are occurring as a measure of achievement against the quality plan; however, these are not being completed according to the organisation’s current schedule. Also, corrective action processes for any shortfalls in internal audits are not always being completed in a timely manner due to breakdowns in the transfers of information. Internal audits are undertaken according to the developed schedule. Associated corrective actions are completed and reported through the quality and risk management system to demonstrate achievement. PA LowReporting Complete24/09/2021
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Not all staff performance appraisals have been completed over the past 12 months as required by human resource policies. Each staff person has completed a performance appraisal with a manager within the previous twelve months. PA LowReporting Complete24/09/2021
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).Assessments for clients using restraints have not covered the requirements of the standard and approval and assessment processes not well documented. Assessments for clients using a restraint cover (a) to (h) of the standard and are fully documented within the resident’s files and within registered nurse/restraint approval meetings minutes. PA ModerateReporting Complete24/09/2021
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).There is a lack of clarity in the residents’ documentation about the detail regarding the use of restraint, duration, outcome and details listed in (a) to (g) in the standard. Records of restraint monitoring lack the necessary details and the times of restraint use are not consistent with those that are recorded. Restraint use and monitoring records are 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 requirements as listed in (a) to (g) of this standard. PA LowReporting Complete24/09/2021
Each episode of restraint is evaluated in collaboration with the consumer and shall consider: (a) Future options to avoid the use of restraint; (b) Whether the consumer's service delivery plan (or crisis plan) was followed; (c) Any review or modification required to the consumer's service delivery plan (or crisis plan); (d) Whether the desired outcome was achieved; (e) Whether the restraint was the least restrictive option to achieve the desired outcome; (f) The duration of the restraint episode… (this text has been trimmed due to space limits).Dates of the last review of restraint use are recorded, however, records are sparse and do not adequately inform whether required processes are followed and associated risks are mitigated. The use of each restraint is evaluated in collaboration with the resident’s family/whānau/EPOA and their GP according to (a) to (k) of the standard. PA LowReporting Complete24/09/2021
Services conduct comprehensive reviews regularly, of all restraint practice in order to determine: (a) The extent of restraint use and any trends; (b) The organisation's progress in reducing restraint; (c) Adverse outcomes; (d) Service provider compliance with policies and procedures; (e) Whether the approved restraint is necessary, safe, of an appropriate duration, and appropriate in light of consumer and service provider feedback, and current accepted practice; (f) If individual plans of care/… (this text has been trimmed due to space limits).Restraint monitoring and quality review processes are not currently meeting the requirements of the standard. Comprehensive reviews of all restraint use are undertaken regularly and cover the requirements of (a) to (h) in this standard. PA LowReporting Complete24/09/2021

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. 

From 1 June 2009 to 28 February 2022 rest homes were audited against the Health and Disability Services Standards NZS 8134:2008. These standards have been updated, and from 28 February 2022 rest homes are audited against Ngā Paerewa Health and Disability Services Standard NZS 8134:2021.

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 Ngā Paerewa Health and Disability Services Standard.

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: 27 January 2021

Audit type:Certification Audit

Audit date: 17 September 2019

Audit type:Surveillance Audit

Audit date: 09 January 2018

Audit type:Certification Audit

Audit date: 11 September 2017

Audit type:Surveillance Audit

Audit date: 31 August 2016

Audit type:Provisional Audit

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