Yellow discharge, smelly and surrounded by cellulitis. That was the state of an elderly resident's calf wound weeks after Manukau's Summerset rest home staff failed to treat it.

The rest home were found in breach of the Code of Health and Disability Services Consumers' Rights for failures in the provision of wound care to an elderly woman, a decision report released today revealed.

The woman's injured right calf was assessed and treated by a nurse at Summerset and it was recorded that the dressing was to be changed after three days. This did not happen.

There was also no Short Term Care Plan created and no photos were taken of the wound, as required.

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The woman's family became concerned that their loved one was in a lot of pain, so they took her to her GP.

The GP recorded that there was a yellow discharge from the wound, that it was smelly, that the dressing was wet, and that there was cellulitis surrounding the wound.

On a second visit to her GP, the dressing was changed again and she was referred to a home healthcare company for ongoing care but progress notes showed no treatment had been recorded.

The following day the woman's family discharged her from the rest home.

As a result of the decision, Deputy Health and Disability Commissioner Rose Wall told the rest home to write a formal written apology to the woman.

Summerset CEO Julian Cook said they had sincerely apologised to the former resident for the distress caused over the treatment received while in Summerset's care.

"We regret that the resident was not provided with the level of care we pride ourselves on at Summerset.

"This incident occurred two years ago and we have made significant changes to our processes and policies at the facility concerned," Cook said.

Wall also asked Summerset to provide the Health and Disability Commission with the training material and records associated with the wound management policy implemented in May.

A random audit of the wound care documentation was also put in place to assess compliance of the rest home.

Cook said they will take on board any further recommendations the Health and Disability Commissioner makes in regards to this investigation.

Back in May, 15 maggots were found in a rest home resident's wound after dressings weren't changed frequently enough.

These horror cases comes after a Herald review of more than 1000 audit reports for the country's 651 facilities since 2016 found more than a third had significant shortfalls related to resident care.