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 2021|
|Certification period||24 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: 02 July 2019
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Reporting of quality data, apart from numbers, was not evidenced in the RN and general staff meeting minutes. Although the RNs interviewed stated they do discuss any trends, the HCAs stated they are not provided with results including any trends.||Provide evidence that quality data including clinical indicators and trends are reported to all clinical staff and recorded in the meeting minutes.||PA Low||Reporting Complete||27/02/2020|
|The appointment of appropriate service providers to safely meet the needs of consumers.||Not all staff files reviewed evidenced position descriptions, including position descriptions for the restraint and infection control coordinators.||Provide evidence that all staff have position descriptions on file.||PA Low||Reporting Complete||27/02/2020|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||(i)Medication competencies for the CNL and one RN have been signed and dated by the general manager who does not have a current practising certificate and does not have a medication competency. (ii)Restraint competencies were not available for review. (iii)Performance appraisals for RNs have been reviewed and signed by the general manager who does not hold a current practising certificate. (iv)Health care assistants are checking controlled drugs on the night shift without a competed second check… (this text has been trimmed due to space limits).||(i)Ensure medication competencies for the CNL and all RNs are undertaken including sign off, by an appropriate person with a current practising certificate who has a current competency. (ii)Provide evidence that restraint competencies have been completed and are current. (iii)Ensure performance appraisals for RNs are reviewed and signed by appropriate person with a current practising certificate. (iv)Provide evidence that health care assistants rostered on the night shift have current second ch… (this text has been trimmed due to space limits).||PA Moderate||Reporting Complete||27/02/2020|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Not all staff files have evidence of a completed orientation.||Provide documented evidence that all staff have completed an orientation.||PA Low||Reporting Complete||27/02/2020|
|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 residents’ documents and resident files reviewed did not all contain unique resident identifiers on progress notes, short term care plans, multidisciplinary meetings, assessment and photos of residents’ wounds.||Ensure that all individual documents related to residents have uniquely identifying information to identify who the resident is.||PA Low||Reporting Complete||27/02/2020|
|The organisation is managed by a suitably qualified and/or experienced person with authority, accountability, and responsibility for the provision of services.||The general manager who is an RN does not hold a current practising certificate and the clinical nurse leader is not able to undertake responsibilities concerning the clinical service because the CNL is rostered on full time as an RN working on the floor.||Provide evidence that D17.4ba of the ARRC Contract between Lifecare Cambridge and the DHB, relating to the employment of a clinical manager is met.||PA Moderate||Reporting Complete||27/02/2020|
|All records are legible and the name and designation of the service provider is identifiable.||White out is being used in a number of organisational/management documents.||Ensure that white out is not used to erase wording on a legal document.||PA Low||Reporting Complete||27/02/2020|
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: 02 July 2019
Audit type:Certification Audit
Audit type:Surveillance Audit
Audit type:Certification Audit
Audit type:Partial Provisional Audit; Surveillance Audit
Audit type:Certification Audit