Premise details
- Address
- 50 Mt Herbert Road Waipukurau 4200
- Total beds
- 42
- Service types
- Geriatric, Medical, Rest home care
Certification/licence details
- Certification/licence name
- Kaylex Care (Waipukurau) Limited - Mt Herbert House
- Current auditor
- The DAA Group Limited
- End date of current certificate/licence
- Certification period
- 24 months
Provider details
- Provider name
- Kaylex Care (Waipukurau) Limited
- Street address
- 4A Roberts Road Matakatia Whangaparaoa 0930
- 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 engage with people receiving services to assess and develop their individual care or support plan in a timely manner. Whānau shall be involved when the person receiving services requests this. | People receiving services at Mt Herbert are not always receiving medical and pharmaceutical review services within the required timeframes, and interRAI assessments were not being completed as required. | Provide evidence residents receive medical services, a review of their medications and an up-to-date interRAI assessment within the required timeframes. | PA Low | 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. | Not all shifts at the facility are covered by an RN as required under the service’s contract with Te Whatu Ora. There are insufficient RNs employed to cover RN leave. | Provide evidence that sufficient numbers of RNs are employed to cover the facility 24/7 including when RN staff are on leave. | PA Low | In Progress | |
| Service providers shall evaluate progress against quality outcomes. | The internal audit schedule has not been adhered to, and not all internal audits have been fully completed with corrective actions generated and addressed as required through policy. There was no record of neurological observation having been fully completed following unwitnessed falls. | Provide evidence that the internal audit schedule is being adhered to, with findings and corrective actions documented and addressed. Provide evidence that unwitnessed falls are having neurological observations fully completed. | PA Moderate | 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 | Care plans reviewed did not describe fully all the care the residents require to address their needs. Early warning signs that may adversely affect a resident’s wellbeing were not always being recorded. | Provide evidence that care plans fully describe all the care the residents require to address their needs, and that early warning signs that may adversely affect a resident’s wellbeing are recorded and being monitored. | PA Moderate | In Progress | |
| The following aspects of the system shall be performed and communicated to people by registered health professionals operating within their role and scope of practice: prescribing, dispensing, reconciliation, and review. | The administration of CD liquids at Mt Herbert, during the observed medication round, was not consistent with best practice guidelines. | Provide evidence that CD medications are checked out by two people who then both go to the resident to ensure the right resident receives the right medication. | PA Moderate | In Progress | |
| The decision to approve restraint for a person receiving services shall be made: (a) As a last resort, after all other interventions or de-escalation strategies have been tried or implemented; (b) After adequate time has been given for cultural assessment; (c) Following assessment, planning, and preparation, which includes available resources able to be put in place; (d) By the most appropriate health professional; (e) When the environment is appropriate and safe. | Consents were not in place for two of six restraints in use, and cultural considerations had not been taken into account during restraint assessment. | Provide evidence that all restraints are consented for prior to use and that the resident’s culture is considered as part of the restraint process. | PA Moderate | In Progress | |
| The frequency and extent of monitoring of people during restraint shall be determined by a registered health professional and implemented according to this determination. | The frequency and extent of monitoring of residents during restraint was not determined by the RN for all restraints in use as required by policy. Where the frequency and extent of monitoring of residents was determined, either by the RN or through the policy requirements, the monitoring regime had not been adhered to. Five of six restraints in use did not have monitoring requirements recorded in their records. | Ensure the frequency and extent of monitoring of residents using restraint is documented and that monitoring is implemented when residents are using a restraint. | PA Moderate | In Progress | |
| My service provider shall practise open communication with me. | Mt Herbert staff do not always keep whānau informed of medical updates, incidents or accidents that have occurred or changes in the residents’ conditions. Residents, visitors and whānau are often unaware of the name of staff members they are communicating with. | Provide evidence that Mt Herbert is keeping whānau informed of changes in the resident’s condition, medical updates, and any incidents or accidents that have occurred. Ensure residents, whānau and visitors have a means to identify which staff member they are taking to. | PA Moderate | In Progress | |
| Service providers shall conduct comprehensive reviews at least six-monthly of all restraint practices used by the service, including: (a) That a human rights-based approach underpins the review process; (b) The extent of restraint, the types of restraint being used, and any trends; (c) Mitigating and managing the risk to people and health care and support workers; (d) Progress towards eliminating restraint and development of alternatives to using restraint; (e) Adverse outcomes; (f) Compliance w | Six-monthly review of the use of restraint has not taken place. | Provide evidence that six-monthly review of the use of restraint is taking place. | PA Moderate | In Progress | |
| Each episode of restraint shall be documented on a restraint register and in people’s records in sufficient detail to provide an accurate rationale for use, intervention, duration, and outcome of the restraint, and shall include: (a) The type of restraint used; (b) Details of the reasons for initiating the restraint; (c) The decision-making process, including details of de-escalation techniques and alternative interventions that were attempted or considered prior to the use of restraint; (d) If | Not all restraints in use were documented on the restraint register. Care plans for residents using restraint did not describe in sufficient detail the rationale for use, intervention to be used, duration, and outcome of the restraint, nor were the risks of using restraints documented with associated interventions to prevent injury. | Ensure all restraints in use are documented on the restraint register. Ensure care plans are in place which outline, in sufficient detail, an accurate rationale for use, the intervention, duration of restraint, and outcome of the restraint. The risks of using the restraints are to be fully documented, with associated interventions to prevent injury. | PA Moderate | In Progress | |
| Each episode of restraint shall be evaluated, and service providers shall consider: (a) Time intervals between the debrief process and evaluation processes shall be determined by the nature and risk of the restraint being used; (b) The type of restraint used; (c) Whether the person’s care or support plan, and advance directives or preferences, where in place, were followed; (d) The impact the restraint had on the person. This shall inform changes to the person’s care or support plan, resulting f | Evaluation of the use of restraint had not been undertaken as required by the Standard. | Provide evidence that evaluation of restraint is being completed as required by the Standard. | PA Moderate | 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: Surveillance Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Surveillance Audit
Audit date:
Audit type: Certification Audit
