Profile & contact details

Premises details
Premises nameWindsorcare
Address 1 Horseshoe Lake Road Shirley Christchurch 8061
Total beds81
Service typesMedical, Dementia care, Rest home care, Geriatric
Certification/licence details
Certification/licence nameWindsor House Board of Governors - Windsorcare
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence05 September 2021
Certification period36 months
Provider details
Provider nameWindsor House Board of Governors
Street address 1 Horseshoe Lake Road Shirley Christchurch 8061
Post addressPO Box 27091 Shirley Christchurch 8640

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: 05 February 2020

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Staff attendance numbers at compulsory trainings has remained low in 2017 and 2018 year to date. For example, 18 of 97 staff attended the code of rights and privacy/dignity training, 17 of 97 at the complaints/advocacy training and 19 of 97 at the abuse and neglect training. While staff training records are maintained, there was no documented evidence of how staff that have not attended compulsory training are followed up to ensure they complete. staff that have not completed are followed up. PA LowReporting Complete29/01/2019
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.i) The care plan had not been updated to reflect changes in behaviour and interventions for one dementia care resident. The same resident did not have any interventions documented for unintentional weight loss, and ii) there were no documented interventions for another dementia care resident with changes in behaviour. Ensure care plans reflect the resident current health status, supports and interventions. PA ModerateReporting Complete29/01/2019
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.i) Neurological observations had not been completed as per protocol following seven of ten unwitnessed falls reviewed and ii) the blood pressure for one resident with postural hypotension had not been completed for two consecutive months. Ensure monitoring occurs as required. PA LowReporting Complete29/01/2019

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: 05 February 2020

Audit type:Surveillance Audit

Audit date: 19 July 2018

Audit type:Certification Audit

Audit date: 31 October 2016

Audit type:Surveillance Audit

Audit date: 01 July 2014

Audit type:Certification Audit

Audit date: 09 April 2013

Audit type:Surveillance Audit

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