Premise details
- Address
- 50 Mt Herbert Road Waipukurau 4200
- Total beds
- 62
- Service types
- Dementia care, Rest home care, Geriatric, Medical
Certification/licence details
- Certification/licence name
- Kaylex Care (Waipukurau) Limited - Mt Herbert House and Forget-Me-Not-Village
- 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 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 or of communication to whānau regarding the fall. | 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 and that whānau are being communicated with following the fall. | 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. | Not all shifts at the facility were 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 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 | Four of seven care plans reviewed did not describe fully all the care the residents required to meet their needs. | Provide evidence that care plans describe fully all the care the residents require to meet their needs. | PA Moderate | In Progress | |
| Service providers shall understand and comply with statutory and regulatory obligations in relation to essential notification reporting. | Appropriate and timely notifications of SAC1 and SAC2 incidents and pressure injuries to Te Tāhū Hauora was not occurring due to the inability to access the portal for reporting. | Provide evidence that the FM has access to the reporting portal of Te Tāhū Hauora, and that the required notifications to Te Tāhū Hauora have been made. | 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 using restraint had been determined by the RC but the monitoring regime had not consistently been adhered to. | Ensure the frequency and extent of monitoring of residents using restraint is documented and that monitoring is consistently implemented when residents are using a restraint. | PA Low | 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, or changes in the residents’ condition. Residents, visitors and whānau are unaware of the names of staff members. | Provide evidence that Mt Herbert keeps whānau informed of changes in residents’ condition, medical updates, and accidents and incidents. Ensure staff wear name badges to enable residents, whānau and visitors to identify who they are talking to. | PA Moderate | In Progress | |
| Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided. | Not all staff have been fully orientated to their role. | Provide evidence that all staff have been fully orientated to their role. | PA Low | 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 | |
| Health care and support workers shall have the opportunity to discuss and review performance at defined intervals. | Not all staff have had a performance appraisal completed annually. | Provide evidence that performance appraisals are being completed annually for all staff. | PA Low | In Progress | |
| My complaint shall be addressed and resolved in accordance with the Code of Health and Disability Services Consumers’ Rights. | The service did not comply with Right 10 of the Code, which requires consumers to have their complaints managed fairly, promptly, and in accordance with policy. Complainants had not been made aware in any correspondence of their right to forward their complaint to the HDC if they were not satisfied with the outcome of their complaint. An accurate, integrated restraint register was not in place. | Provide evidence that the service has reviewed and strengthened its complaints management system to ensure full compliance with Right 10 of the Code. Provide evidence that information on the right of the complainant to refer their complaint to the HDC if they were not satisfied with the outcome of their complaint had been provided, and that the restraint register is accurate and integrated. | PA Low | 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 three-monthly as required. | Provide evidence that evaluation of restraint use is being completed at three-monthly intervals. | 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 corrective action manager.
- Date action reported complete
The date that the corrective action manager 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: Partial Provisional Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Surveillance Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Surveillance Audit
