Kaikohe Care

Profile & contact details

Premises details
Premises nameKaikohe Care
Address 22 Bisset Road Kaikohe 0405
Websitewww.kaikohecare.co.nz
Total beds59
Service typesGeriatric, Medical, Dementia care, Rest home care
Certification/licence details
Certification/licence nameLexhill Limited - Kaikohe Care
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence18 November 2022
Certification period36 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: 14 April 2021

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.(i).The business strategy and management plan 2020 and the quality plan have not been reviewed to show progress against goals documented. (ii). The plans have no relevance to the service as stated by the temporary facility manager. (i). Review the business strategy and management plan and quality plan prior to development of the current plan. (ii). Provide plans to guide the service around improvement. PA LowReporting Complete18/01/2022
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.Quality and risk data (e.g. falls, skin tears, results of audits and surveys) is not being discussed at relevant and regular quality and other meetings with evidence of improvements made as a result of the discussions. Ensure quality and risk data including results of audits and surveys and topical issues are discussed at relevant regular meetings so that areas for improvement can be identified. PA ModerateReporting Complete18/01/2022
The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk.Five of 16 forms that documented an unwitnessed fall or a hit to the head did not have neurological observations taken as per policy Ensure that neurological observations are taken as per policy for residents who have an unwitnessed fall or a hit to the head. PA LowReporting Complete18/01/2022
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.Four of the five staff files reviewed did not have a performance appraisal completed annually as per policy. Ensure that all staff have a performance appraisal completed annually as per policy. PA LowReporting Complete18/01/2022
All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.(i). The food control plan was not able to be sighted on the day of audit. (ii). Kitchen staff are not kept informed of residents who are losing weight (i). Ensure that the food control plan is current. (ii). Ensure RNs keep kitchen staff informed of residents who are losing weight with interventions to support weight gain to be put in place PA ModerateReporting Complete18/01/2022
Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer.A reassessment, evaluation of care and a revised care plan has not been completed for a resident in the rest home who has been in respite care for over six months. Complete a reassessment, evaluation of care and a revised care plan for a resident in the rest home who has been in respite care for over six months. PA LowReporting Complete18/01/2022
Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.The activity plan in the dementia unit is not well implemented. This continues to be an area requiring improvement. Implement an activity plan in the dementia unit specifically for those residents in the unit. PA ModerateReporting Complete18/01/2022
Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome.The registered nurse completing a review of the care plan does not document an evaluation of the previous plan prior to formulating the revised plan. Document an evaluation of the previous care plan prior to formulating the revised care plan PA LowReporting Complete18/01/2022
The organisation, through its infection control committee/infection control expert, determines the type of surveillance required and the frequency with which it is undertaken. This shall be appropriate to the size and complexity of the organisation.The IC coordinator was not aware that there was a policy around management of scabies and had not read the policy. A plan to manage the outbreak has not been documented. External providers have not been notified of the outbreak apart from the GP who has been involved in treating each resident. Progress notes in three of the resident records who have been identified as being treated for scabies do not document if the treatment has been effective of effective management of symptoms. Staff have… (this text has been trimmed due to space limits).i) Provide training for IC coordinator around policies and procedures related to infection control and in particular to outbreak management. ii) Document a plan to manage the outbreak of scabies. iii) Maintain contact with external providers both to notify them of any outbreak and to receive advice and guidance on management. iv) Document if the treatment has been effective in management of scabies for those treated and document effective management of symptoms. v) Provide training for staff… (this text has been trimmed due to space limits).PA ModerateReporting Complete18/01/2022

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. 

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.

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 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) 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: 14 April 2021

Audit type:Surveillance Audit

Audit date: 02 October 2020

Audit type:Partial Provisional Audit

Audit date: 09 January 2020

Audit type:Partial Provisional Audit

Audit date: 05 September 2019

Audit type:Certification Audit

Audit date: 31 May 2019

Audit type:Partial Provisional Audit

Audit date: 14 March 2019

Audit type:Surveillance Audit

Audit date: 24 September 2018

Audit type:Surveillance Audit

Audit date: 21 August 2017

Audit type:Certification Audit

Audit date: 18 August 2016

Audit type:Provisional Audit

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