Kaikohe Care

Profile & contact details

Premises details
Premises nameKaikohe Care
Address 22 Bisset Road Kaikohe 0405
Websitewww.kaikohecare.co.nz
Total beds58
Service typesDementia care, Rest home care, Geriatric, Medical
Certification/licence details
Certification/licence nameLexhill Limited - Kaikohe Care
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence08 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: 09 January 2020

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.(i) The in-service education and training provided for staff reflected low attendance rates with attendance consistently below 50%. Online training did not reflect which staff have completed the modules being offered. (ii) RNs are frequently recruited from overseas. The RNs interviewed stated that they had not received any cultural training relating to Māori values and beliefs. (Note: There are 17 residents at the facility that identify as Māori). The facility manager confirmed cultural trai… (this text has been trimmed due to space limits).(i) Ensure staff attend all mandatory education and training. (ii) Ensure Māori cultural training begins during the new staff induction and continues regularly. This is especially important for RN staff who arrive to work at the facility from overseas. (iii) Ensure staff who handle chemicals participate in chemical safety training. (iv) Ensure specific training identified as per DHB recommendations are implemented. PA LowReporting Complete21/01/2020
All buildings, plant, and equipment comply with legislation.(i) The environment has areas that require repair, including peeling wallpaper, ceilings that need painting and painting that is chipped and peeling. (ii) The dementia unit has a strong smell of urine (advised that since the audit the service has removed the pad bin which was the main source of the smell). (i) Ensure all areas (eg, resident bedrooms) that require repair are addressed. (ii) Ensure the dementia unit has a fresh and clean odour. PA LowReporting Complete21/01/2020
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.There were a sample of corrective actions identified that have not been implemented. For example, corrective actions determined from complaints received (eg, training staff on the identification of pressure injuries, activation of EPOA, evaluating the electronic clinical record system), corrective actions determined from internal audit results (eg, challenging behaviours, cleaning, laundry), and corrective actions determined from resident meetings (eg, three consecutive sets of meeting minutes … (this text has been trimmed due to space limits).Ensure that corrective actions identified are implemented and signed off to indicate their effectiveness. PA LowReporting Cancelled
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.(i) Quality and risk data (eg, falls, skin tears) is not being collated, analysed and evaluated. (ii) Meeting minutes and interviews with staff do not indicate quality and risk results are communicated to staff. (i) Ensure quality and risk data is collated, analysed and evaluated each month to identify areas for improvements. (ii) Ensure quality and risk data results are communicated to staff. PA LowReporting Cancelled
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.i) Staff attendance at mandatory training could not be verified to ascertain if attendance rates had improved since the previous audit. ii) One cleaner and one cook interviewed confirmed that they have not had chemical safety training. This is available as online training, but staff interviewed have not completed this module. The facility manager stated she plans to address this shortfall when next speaking to the chemical supplier. i) Ensure staff attend all mandatory training with documented evidence to support this. ii) Ensure staff who handle chemicals take part in chemical safety training. PA ModerateReporting Complete24/02/2020

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. 

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 reports

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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