Profile & contact details

Premises details
Premises nameWindsorcare
Address 1 Horseshoe Lake Road Shirley Christchurch 8061
Total beds81
Service typesRest home care, Geriatric, Medical, Dementia care
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 2024
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: 28 June 2021

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.There were inconsistent entries in progress notes by a registered nurse (gaps of 15 – 30 days) in two rest home and two dementia files reviewed. Ensure progress notes include regular entries from a registered nurse to document regular resident contact/assessment. PA LowReporting Complete21/10/2021
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.The following shortfalls were identified: i) Four wounds (two in the rest home and two in the hospital), the wound documentation/management was not completed within the stated dressing frequency. ii) Repositioning charts for one resident with high risk of skin breakdown in the hospital has not been completed within the stated frequency; this also included the infrequent monitoring of pain related to the chronic wound; and iii) Challenging behaviour recordings (one resident in the dementia unit)… (this text has been trimmed due to space limits).Ensure monitoring forms are completed within the required stated timeframes PA LowReporting Complete21/10/2021
Where progress is different from expected, the service responds by initiating changes to the service delivery plan.Evaluations of two (of two) residents in the dementia unit reflect interventions including allied health instructions such as a diet change, outpatient appointments. Interventions were not updated in the care plan. Ensure evaluations different from expected outcomes are documented in the care plan by making the necessary changes to the goals and interventions. PA LowReporting Complete21/10/2021

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: 28 June 2021

Audit type:Certification Audit

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

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