Premise details
- Address
- 194 Nixon Street Hamilton East Hamilton 3216
- Total beds
- 47
- Service types
- Rest home care, Dementia care
Certification/licence details
- Certification/licence name
- Kaylex Care Limited - Eastcare Residential Home
- Current auditor
- The DAA Group Limited
- End date of current certificate/licence
- Certification period
- 12 months
Provider details
- Provider name
- Kaylex Care Limited
- Street address
- 194 Nixon Street Hamilton East Hamilton 3216
- Postal address
Progress on issues from the last audit
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.
| Outcome required | Found at audit | Action required | Risk rating | Action status | Date action reported complete |
|---|---|---|---|---|---|
| Service providers shall implement a process to support a safe, timely, seamless transition, transfer, or discharge. | Arrangements for the transfer of a resident to public hospital was not carried out according to the instructions of the OM who was in charge. There was a lack of follow up and communication with the receiving service within 24 hours of the transfer. | Ensure transfers of residents to other services occur according to agreed processes in a safe, timely and supported manner | PA Moderate | In Progress | |
| Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care. | The previous quality and risk management system was not being used effectively. Not all risks to service delivery and care were identified and there was no evidence of action being undertaken to mitigate risk and improve service delivery and care. | Ensure the new quality and risk management system is fully implemented in ways that identify and prevent risks and lead to improvements in service delivery and care. | PA Moderate | In Progress | |
| Governance bodies shall ensure service providers’ structure, purpose, values, scope, direction, performance, and goals are clearly identified, monitored, reviewed, and evaluated at defined intervals. | Key strategies in the 2024/2025 business plan or quality plan were not being reviewed for progress. | Ensure that key strategic/business and performance planning documents are reviewed for progress at regular intervals. | PA Low | In Progress | |
| Governance bodies shall appoint a suitably qualified or experienced person to manage the service provider with authority, accountability, and responsibility for service provision. | There is no on-site manager with suitable skills, experience or knowledge about the requirements of the aged care sector. | Ensure a suitable facility manager is appointed. | PA Moderate | In Progress | |
| Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services. | There were insufficient care and activities staff on morning and evening shifts. The hours of work for the two RN/CNLs did not maximise RN attendance in the home or provide effective and efficient communication with staff and residents. Changes to staff allocation and CNL/RN hours were announced on audit days, with instructions to the CNLs to undertake twice-daily rounds and report findings to the OM. These changes were to be implemented on Monday 17 February. | Ensure there are adequate numbers of skilled and experienced staff allocated to work in all areas of the home. | PA Moderate | In Progress | |
| Service providers shall evaluate progress against quality outcomes. | Progress towards meeting quality outcomes was not being monitored, evaluated and reported. | Ensure that methods and systems are implemented which allow regular and effective evaluation of progress against quality goals/indicators/outcomes | PA Low | In Progress | |
| My service providers shall provide opportunities for discussion and clarification about my rights. | Not all residents were informed of their rights and provided with opportunities for discussion and clarification about their rights. | Ensure residents are informed about their rights and are given an opportunity for discussion and clarification about their rights. Ensure that meetings with residents are convened by an independent or impartial person, so residents feel free to participate and express themselves. | PA Moderate | In Progress | |
| Service providers shall ensure their health care and support workers have the skills, attitudes, qualifications, experience, and attributes for the services being delivered. | Staff working in the dementia units had not achieved the unit standards specified in the ARRC within 18 months of commencing employment. | Ensure that all staff working with dementia care residents have achieved or are progressing the four-unit standard LCP-Dementia with completion of these within 18 months of commencing employment. | PA Moderate | In Progress | |
| Meaningful activities shall be planned and facilitated to develop and enhance people’s strengths, skills, resources, and interests, and shall be responsive to their identity. | There are no qualified or experienced activities assessor or planner to identify residents’ individuality, interests and activity preferences. | Ensure that meaningful activities are planned and facilitated by qualified or experienced staff to enhance residents’ strengths, skills, resources, and interests and shall be responsive to their identity. | PA Moderate | In Progress | |
| The physical environment, internal and external, shall be safe and accessible, minimise risk of harm, and promote safe mobility and independence. | The external physical environment was neither safe, well maintained, tidy, or comfortable. Dementia residents have limited outdoor space for moving independently and freely. There is no ready access to the outside emergency assembly area in the car park when exiting the external side doors in Koromiko and Pukeko wings. The ‘Emergency egress’ gate is padlocked. | Ensure all external areas and furniture is safe, promotes independence, mobility and minimises harm (of falls and injuries, poisoning, absconding, or sunburn). Ensure the emergency egress route from the north side of the building to the evacuation assembly area is accessible. | PA Moderate | In Progress | |
| My service provider shall facilitate support for me in accordance with my wishes, including independent advocacy. | Residents described situations where they had not been supported by staff nor offered access to independent advocacy. | Ensure residents are supported, or that access to independent support is facilitated. Ensure residents are provided with information and/or contact details for independent advocates. | PA Moderate | In Progress | |
| Service providers shall ensure the skills and knowledge required of each position are identified and the outcomes, accountability, responsibilities, authority, and functions to be achieved in each position are documented. | No clearly defined job descriptions for the role of senior care givers and the infection prevention coordinator were available. | Ensure job descriptions identify the role for each position, meet the requirements of this criterion, and are documented. | PA Low | In Progress | |
| There is an IP role, or IP personnel, as is appropriate for the size and the setting of the service provider, who shall: (a) Be responsible for overseeing and coordinating implementation of the IP programme; (b) Have clearly defined responsibility for IP decision making; (c) Have documented reporting lines to the governance body or senior management; (d) Follow a documented mechanism for accessing appropriate multidisciplinary IP expertise and advice when needed; (e) Receive continuing education | The current job description for IP personnel does not include responsibility for AMS. IP personnel have not undertaken continuing training for IP and AMS. | Ensure the IP job description includes responsibility for AMS and training is undertaken by the IP co-ordinator for IP and AMS. | PA Moderate | In Progress | |
| Service providers shall implement systems to determine and develop the competencies of health care and support workers to meet the needs of people equitably. | The staff education system was not adequately developing staff knowledge and competencies (RNs, care givers, activities staff). | Ensure that staff demonstrate competency in working with people with dementia, that they understand their obligations under Te Tiriti o Waitangi, Māori constructs of oranga, disparity and inequities, and they use this knowledge in their daily practice to prevent/reduce inequity and facilitate wellbeing outcomes for all residents. | PA Moderate | In Progress | |
| There shall be a formally agreed mechanism for accessing appropriate IP and AMS expertise that assists with defining the strategic direction and provides advice to the governance body. | There was no evidence of formal links with Te Whatu Ora Waikato for IP and AMS expert advice. | Implement a formally agreed mechanism for accessing IP and AMS expertise | PA Low | In Progress | |
| Fundamental to the development of a care or support plan shall be that: (a) Informed choice is an underpinning principle; (b) A suitably qualified, skilled, and experienced health care or support worker undertakes the development of the care or support plan; (c) Comprehensive assessment includes consideration of people’s lived experience; (d) Cultural needs, values, and beliefs are considered; (e) Cultural assessments are completed by culturally competent workers and are accessible in all settin | Early warning signs and risks that adversely affected a resident’s wellbeing were not recorded, identified or investigated. There were no interventions evident to prevent escalation. There was no follow up 24 hours after the resident was transferred to public hospital to ascertain/prevent risks and check on the residents’ welfare, prognosis or treatment plan. Residents’ lived experience and cultural needs are not being considered in support plans. Cultural assessments are not being complete | Ensure early warning signs and risks that adversely affect residents’ wellbeing are recorded, with prevention or escalation for appropriate intervention. Ensure there is follow up and ongoing communication with other services involved in resident care. Ensure that cultural assessments are completed by culturally competent staff. | PA High | In Progress | |
| People receiving services shall be supported to access their communities of choice where possible. | Residents were not being supported to access their local community | Ensure planning and co-ordination of the activities programme to include regular community access for residents. | PA Moderate | In Progress | |
| Service providers shall follow the National Adverse Event Reporting Policy for internal and external reporting (where required) to reduce preventable harm by supporting systems learnings. | Incident data is not being sufficiently analysed, reviewed and reported according to methods described in the National Adverse Events Reporting Policy which lead to learning opportunities and system improvement/system learning. | Apply learning review methods for analysing and reporting incident/accident (adverse event) data to prevent recurrence and reduce harm. | PA Moderate | In Progress | |
| Service providers shall ensure there is a system to identify, plan, facilitate, and record ongoing learning and development for health care and support workers so that they can provide high-quality safe services. | The staff education system does not readily determine the learning needs of individual staff or reliably record the training attended and professional development for each staff member. | Implement a systematic approach to staff training and development which readily identifies gaps in knowledge or achievement/competency for each staff member. | PA Moderate | In Progress | |
| In implementing care or support plans, service providers shall demonstrate: (a) Active involvement with the person receiving services and whānau; (b) That the provision of service is consistent with, and contributes to, meeting the person’s assessed needs, goals, and aspirations. Whānau require assessment for support needs as well. This supports whānau ora and pae ora, and builds resilience, self-management, and self-advocacy among the collective; (c) That the person receives services that remov | No involvement of the resident when implementing care plans, and changes in resident needs and risk through regular assessment were not documented. | Ensure there is active involvement with the resident and whānau when implementing care and the needs and risk assessments are ongoing, with changes documented and implemented. | PA Moderate | In Progress | |
| Service providers shall maintain an information management system that: (a) Ensures the captured data is collected and stored through a centralised system to reduce multiple copies or versions, inconsistencies, and duplication; (b) Makes the information manageable; (c) Ensures the information is accessible for all those who need it; (d) Complies with relevant legislation; (e) Integrates an individual’s health and support records. | The personal and health information of people using the service is not integrated and archived records are being stored in ways that are neither accessible nor safe. This is in breach of the New Zealand health records standard and the requirements of this criterion. | Ensure the collection, storage and use of personal and health information of people in the service meets the requirements of the NZ health records standard and this criterion. | PA Moderate | In Progress | |
| Services shall ensure health care and support workers receive Te Tiriti o Waitangi training and that this is reflected in day-to-day service delivery. | Not all staff have been provided training in Te Tiriti o Waitangi. | Ensure that all staff attend Te Tiriti o Waitangi training and that this is embedded in day-to-day service delivery. | PA Low | In Progress | |
| Service providers shall understand and comply with statutory and regulatory obligations in relation to essential notification reporting. | Section 31 notifications have not been reliably submitted. | Ensure that all events requiring notification to funders and HealthCERT occur as required under Section 31 of the Health and Disability Services (Safety) Act 2001. | PA Moderate | In Progress | |
| Service providers shall assist with training and support for people and service providers to maximise people and whānau receiving services participation in the service. | There were no systems, methods or staff whose focus was to encourage residents and whānau to participate in the service. | Implement effective methods which facilitate and support whānau and residents to regularly participate in the service. | PA Low | In Progress | |
| Planned review of a person’s care or support plan shall: (a) Be undertaken at defined intervals in collaboration with the person and whānau, together with wider service providers; (b) Include the use of a range of outcome measurements; (c) Record the degree of achievement against the person’s agreed goals and aspiration as well as whānau goals and aspirations; (d) Identify changes to the person’s care or support plan, which are agreed collaboratively through the ongoing re-assessment and review | Planned reviews of residents’ care plans are not being undertaken within acceptable timeframes. Changes identified were not always documented and implemented. | Ensure that when a resident’s need changes, this is documented, reported and that interventions/actions are implemented. | PA High | In Progress | |
| I shall be empowered to actively participate in decision making. | Residents are not being given time, opportunity or support with their decision-making. | Ensure residents are supported and invited to actively participate in decisions that impact their lives. | PA Moderate | In Progress | |
| Service providers shall establish environments that encourage collecting and sharing of high-quality Māori health information. | There is no collection and sharing of high-quality Māori health information. | Implement methods for the collection and reporting/sharing of Māori health information. | PA Low | In Progress | |
| Service providers, shall evaluate the effectiveness of their AMS programme by: (a) Monitoring the quality and quantity of antimicrobial prescribing, dispensing, and administration and occurrence of adverse effects; (b) Identifying areas for improvement and evaluating the progress of AMS activities. | There was no evidence of the evaluation of the effectiveness of the AMS programme. | Ensure ongoing monitoring and evaluation of the effectiveness of AMS activities with identification of areas for improvement. | PA Low | In Progress | |
| Each person’s room shall have at least one external window, providing natural light, and appropriate ventilation and heating. | Temperatures in the building on the days of audit exceeded WorkSafe recommended temperature range (between 19 to 24 degrees Celsius) There was a persistent and offensive odour in Tui wing. | Implement effective methods and systems to remove/neutralise odours and maintain comfortable temperatures throughout the home. | PA Moderate | In Progress | |
| Service providers shall improve health equity through critical analysis of organisational practices. | There is no system for critically analysing organisational practices to improve health equity. | Develop and implement methods for improving health equity. | PA Low | In Progress | |
| Service providers shall identify and implement appropriate security arrangements relevant to the people using services and the setting, including appropriate identification. | Staff were not wearing identification. | Ensure staff name and designation is visible to residents, visitors and allied health professionals, so they can identify staff and their role.. | PA Low | In Progress | |
| My complaint shall be addressed and resolved in accordance with the Code of Health and Disability Services Consumers’ Rights. | Management of complaints did not meet best known practice or the requirements of the Code. | Ensure that complaints are managed according to service policy and the Code. | PA Moderate | In Progress | |
| My service provider shall prioritise a strengths-based and holistic model ensuring wellbeing outcomes for Māori. | Māori-focused health plans were not being used for residents who identify as Māori. There was no evidence of a strengths-based and holistic model of care ensuring wellbeing outcomes for Māori residents. | Develop and implement Māori-focused care plans to guide day-to-day practices. Support Māori to engage with services and receive the care and support they need. | PA Low | In Progress | |
| Service providers shall invest in the development of organisational and health care and support worker health equity expertise. | There was no evidence of training, systems or methods to develop staff knowledge and expertise in health equity. | Implement methods for developing staff knowledge and expertise in health equity. | PA Low | In Progress | |
| Service providers shall understand Māori constructs of oranga and implement a process to support Māori and whānau to identify their own pae ora outcomes in their care or support plan. The support required to achieve these shall be clearly documented, communicated, and understood. | Māori constructs of oranga are not understood by staff. Pae ora outcomes to support Māori residents are not documented in care plans. | Ensure staff receive training to understand Māori constructs of oranga and use pae ora outcomes in care planning. | PA Moderate | In Progress | |
| Results of surveillance and recommendations to improve performance where necessary shall be identified, documented, and reported back to the governance body and shared with relevant people in a timely manner. | There was no evidence of results of surveillance being used to change practise, maximise quality of care and minimise risk and adverse effects from antibiotic use, such as antimicrobial resistance. | Ensure that surveillance results and recommendations are identified, documented and reported to the directors and other key personnel at Eastcare. | PA Low | In Progress | |
| An approved food control plan shall be available as required. | Food storage does not comply with the FCP. | Ensure all non-conformance areas identified in the FCP and at audit (food storage) are addressed. | PA Low | In Progress | |
| My service provider shall make communication and information easy for all people to access; understand; and use, enact, or follow. | Residents said they were not feeling respected and listened to about their choices. The complaint documents and care plans demonstrated gaps in communication. | Ensure that all communication and information is timely, responsive, understood and enacted to enhance residents’ wellbeing. | PA Moderate | In Progress | |
| The Code of Health and Disability Services Consumers’ Rights and the complaints process shall work equitably for Māori. | The manner in which complaints were being addressed did not demonstrate a fair, open or equitable approach for residents, including Māori residents. | Ensure that complaints are managed according to service policy and the Code and take into account the unique needs of residents, including the cultural support needs of Māori residents and whānau. | PA Moderate | In Progress | |
| My legal representative shall only make decisions on my behalf in compliance with the law. If my legal representatives make decisions for me, I still have the right to be included. | The CNLs did not understand enactment of EPOAs. Four resident records reviewed had no evidence of EPOAs. | Ensure that CNLs and other staff have received education and demonstrate knowledge regarding enactment of EPOAs. Ensure that each resident has a nominated EPOA documented in their care records. | PA Moderate | In Progress | |
| IP personnel and committees shall participate in partnership with Māori for the protection of culturally safe practice in IP, and thus acknowledge the spirit of Te Tiriti. | IP personnel not participating in partnership with Māori to provide culturally safe IP practice. | Establish an ongoing partnership with Māori to maintain culturally safe IP practice. | PA Low | In Progress |
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
About audit reports
Audit reports for this rest home’s latest audits can be downloaded below.
Before you begin
Before you download the audit reports, please read our guide to rest home certification and audits. The guide gives an overview of the auditing process and explains what the audit reports mean.
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.
Before 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) appear on the rest home’s page. As the rest home completes the required actions, the status on the website updates.
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Surveillance Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Surveillance Audit
Audit date:
Audit type: Certification Audit
