Kaikohe Care Centre

Profile & contact details

Premises details
Premises nameKaikohe Care Centre
Address 22 Bisset Road Kaikohe 0405
Total beds61
Service typesDementia care, Rest home care, Medical
Certification/licence details
Certification/licence nameLexhill Limited - Kaikohe Care Centre
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence08 November 2017
Certification period12 months
Provider details
Provider nameLexhill Limited
Street address27 Yelash Road Massey Auckland 0614
Post addressP.O.BOX 100-347 North Shore Auckland 0745

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: 18 August 2016

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.The 2016 audit schedule is not being completed as planned, with eight audits not completed in 2016 (year-to-date). The facility manager reported that she delegates internal audits to staff but that these have not always been completed and returned. Ensure internal audits are completed as per the internal audit schedule. PA LowReporting Complete20/03/2017
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Fifty-eight staff are employed by the service with 44 care staff (36 caregivers and activities staff, and eight RNs). The 2016 in-service education and training provided for staff reflected low attendance rates (eg, code of rights (13 attended), abuse neglect (8), challenging behaviours (8), infection control (13), skin care (11), diabetes (8), restraint minimisation (3), chemical handling (2)). Ensure staff attend all mandatory education and training and can demonstrate that they have each attended 8 hours annually as per the aged related care (ARC) contract. PA LowReporting Complete20/03/2017
A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines.i) Three of fourteen medication chart signing sheets reviewed (a sample from each area) did not evidence that medications had been administered as prescribed; and ii) Two of fourteen medication charts did not document the commencement date of the prescribed medication. i) Ensure that medications are administered as prescribed; and ii) ensure that all medication orders include a commencement date. PA ModerateReporting Complete20/03/2017
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.i) Two rest home and three hospital resident (including one hospital YPD) diversional therapy plans, did not document the interventions required to assist the residents to achieve their desired goals; ii) one rest home resident care plan did not document the management of diagnosis of diabetes; and iii) two of four behavioural management plans (one dementia and one hospital) reviewed did not document resident specific de-escalation or distraction techniques that could be used to prevent or manag… (this text has been trimmed due to space limits).i) Ensure that diversional therapy plans document the interventions required to achieve goals; ii) ensure that nursing management of medical conditions are documented in care plans; and iii) ensure that behavioural management plans document resident specific de-escalation or distraction techniques. PA ModerateReporting Complete20/03/2017
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).i) Risks associated with restraint use were not being recorded on the restraint assessment in two of two residents’ files reviewed; and ii) Restraint use was not documented in one of two care plans where restraints were being used. i) Ensure risks associated with the use of restraint are identified as part of the restraint assessment process; and ii) Ensure residents using restraint have restraint use identified in their care plans. PA LowReporting Complete17/07/2017

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: 18 August 2016

Audit type:Provisional Audit

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