Kaikohe Care Centre
Profile & contact details
|Premises name||Kaikohe Care Centre|
|Address||22 Bisset Road Kaikohe 0405|
|Service types||Rest home care, Medical, Geriatric, Dementia care|
|Certification/licence name||Lexhill Limited - Kaikohe Care Centre|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||08 November 2019|
|Certification period||24 months|
|Provider name||Lexhill Limited|
|Street address||27 Yelash Road Massey Auckland 0614|
|Post address||P.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: 21 August 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||i) No corrective actions were developed around satisfaction survey results for 2017 (e.g., four of ten survey results identified that residents were unhappy with the food). ii) The corrective action plans identified from internal audits that have taken place since June 2017, have not been implemented. For example, three internal audits indicated that issues identified would be discussed in staff meetings but meeting minutes do not reflect any evidence of discussions taking place.||i) Ensure corrective actions are developed from satisfaction surveys that address negative trends in data. ii) Ensure that corrective actions identified from internal audits are implemented.||PA Low||In Progress|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||(i)Fifty-three staff are employed by the service. The 2017 in-service education and training provided for staff reflected low attendance rates with attendance consistently below 50%. Only two of eight staff files reviewed indicated that they had maintained eight hours per year of education. The facility manager plans to begin in-service training during handovers but reports that she has not implemented this initiative yet. (ii) The service has struggled ensuring enough interRAI trained staff … (this text has been trimmed due to space limits).||(i)Ensure staff attend all mandatory education and training and can demonstrate that they have each attended eight hours annually as per the aged related care (ARC) contract. (ii) continue to access interRAI training for RNs to ensure contract timeframes are met for assessments.||PA Moderate||In Progress|
|All buildings, plant, and equipment comply with legislation.||(i) One communal bathroom had a wooden shower seat to be replaced. Another communal bathroom had broken wall panelling requiring repair. (ii) One resident bedroom in the hospital wing had peeling ceiling paint and damaged skirting requiring repair.||Ensure all reactive maintenance issues are addressed and comply with legislation.||PA Low||In Progress|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||Six (four hospital, one dementia and one rest home) of seven long term resident files sampled did not have documented interventions to address current assessed needs: i)One hospital resident with spinal injury did not have interventions or LTCP documented. ii)One resident in the dementia unit (tracer) with pressure injury. The care plan did not include interventions for pressure injury prevention/management, current activities of daily living, falls prevention and pain management. (iii)One hosp… (this text has been trimmed due to space limits).||Ensure that all resident files have documented interventions to guide care.||PA Moderate||In Progress|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||(i) Since June 2017, meeting minutes do not reflect internal audit results being communicated to staff. (ii) Results from the 2017 satisfaction survey, completed earlier in the year, have not been collated to identify trends. (iii) Clinical indicator data has not been evaluated since June 2017.||(i) Ensure audit results are communicated to staff. (ii) Ensure data that is collected from satisfaction surveys are collated, evaluated and used for service improvements. (iii) Ensure clinical indicator data is evaluated to identify areas for improvements.||PA Moderate||In Progress|
|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) Two of sixteen medication chart signing sheets reviewed (dementia care) evidenced that medications had not been administered as prescribed. (ii) One medication chart (dementia resident) did not document the signature of the prescriber for one regular medication administered and one of two hospital medication signing sheets reviewed, evidenced 24 hour paracetamol charted QID (regular medications) and PRN tablets had been given prior to prescribed frequency and over maximum dose recommended w… (this text has been trimmed due to space limits).||(i) Ensure that all medication has been given as prescribed. (ii) Ensure that all medication administered has been signed by the prescriber. (iii) Ensure the controlled drug register is completed as per required legislation. (iv) Ensure all medications are stored as per required legislation. (v) Ensure all expired medications are disposed of as per required legislation.||PA Moderate||In Progress|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||(i) A recent cut in staffing levels two months ago, reflects that caregiver staff in the rest home wing struggle to meet the current needs of the residents on AM and PM shifts. Only one caregiver is rostered for 21 residents. Three rest home level residents require two assists. Caregiver staff in the hospital wing are reported as frequently being too busy with hospital level residents to assist with the rest home level residents. This shortage in staffing was confirmed in staff and residents… (this text has been trimmed due to space limits).||Ensure staffing is adjusted to meet the current needs of the resident. (ii) Ensure the residents in all areas receive an activities programme that meets their needs||PA Moderate||In Progress|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||(i) The clinical nurse leader has not had an orientation specific to her role. (ii) Three further staff files (of eight staff files) were missing documented evidence of staff completing their orientation programme.||(i) Ensure that the clinical nurse leader is orientated to her new role. (ii) Ensure that staff files contain documented evidence that they have completed their induction programme.||PA Moderate||Reporting Complete||16/01/2018|
|Entry criteria, assessment, and entry screening processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies.||Three of eight files (one rest home and two hospital including one respite) did not have signed admission agreements.||Ensure there is a signed admission agreement on file for all residents.||PA Low||Reporting Complete||16/01/2018|
|Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.||There is a minimum of one staff available seven days a week with a current first aid/CPR certificate on the am and pm shifts but not on the night shift||Ensure there is a person trained in first aid across 24/7||PA Moderate||Reporting Complete||16/01/2018|
|An appropriate 'call system' is available to summon assistance when required.||Maintenance staff reported that they were in need of four additional call bell cords in order to ensure that all residents have access to a call bell when lying in bed. It was also noted that in the rest home shower area, where there was previously a call bell cord accessible in each of the showers, there currently is only one call bell just outside of the two showers with a cord that requires residents (if showering independently) to remember to take the call bell into the shower with them. S… (this text has been trimmed due to space limits).||Ensure a call bell is readily accessible to all residents while in bed and when showering.||PA Moderate||Reporting Complete||16/01/2018|
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: 21 August 2017
Audit type:Certification Audit
Audit type:Provisional Audit