Premise details
- Address
- 77 Doon Street Mosgiel 9024
- Website
- http://www.birchleigh.com
- Total beds
- 83
- Service types
- Rest home care, Geriatric, Medical, Dementia care
Certification/licence details
- Certification/licence name
- Birchleigh Management Limited - Birchleigh Residential Care Centre
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- Birchleigh Management Limited
- Street address
- 77 Doon Street Mosgiel 9024
- Postal address
- PO Box 328 Mosgiel 9053
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 |
|---|---|---|---|---|---|
| I shall receive information in my preferred format and in a manner that is useful for me. | Two of four incident reports reviewed from the dementia unit did not evidence relatives’ notification of incidents. | Ensure family/whānau are advised of accidents/incidents. | PA Low | Reporting Complete | |
| Service providers shall implement systems to determine and develop the competencies of health care and support workers to meet the needs of people equitably. | Three of the eleven staff files did not evidence completed staff competencies. | Ensure staff have completed annual competencies in relation to their role as per schedule. | PA Low | Reporting Complete | |
| 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 | i). Three dementia files reviewed did not evidence interventions to guide care staff on individual de-escalation and diversion techniques for management of challenging behaviour. ii). Three dementia files reviewed did not evidence either 24-hour care plans or a documented daily schedule to guide cares. | i). Ensure care plans include sufficient information to guide care staff on management of challenging behaviours. ii). Ensure care plans include sufficient information to guide staff on individual residents. | PA Low | Reporting Complete | |
| 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 | i). Three hospital level care residents at risk of pressure injury did not have repositioning documented two-hourly, as instructed. ii). Three hospital residents utilising restraint did not evidence monitoring completed at required intervals. | i). Ensure that repositioning charts are completed as per required timeframes. ii).iii). Ensure restraint monitoring occurs as per policy. | PA Low | Reporting Complete | |
| A medication management system shall be implemented appropriate to the scope of the service. | i). A controlled drug quantity stocktake has not been completed in the rest home, hospital, or dementia areas in the last 12 months. ii) Two sprays in pharmacy dispensed containers did not evidence opening dates. | i). Ensure quality stocktakes are completed six-monthly as per legislation. ii). Ensure all medication in pharmacy dispensed containers evidences an opening dated and is discarded as per recommendations. | PA Moderate | Reporting 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. | i). One hospital level resident had their first long LTCP completed over four months after admission. ii). Two of two residents (dementia) who required LTCP evaluations did not have these always completed within required timeframes. | i-ii). Ensure LTCPs and evaluations are competed within required timeframes. | PA Low | In Progress | |
| Service providers shall evaluate progress against quality outcomes. | Braeside (hospital) and Janefield (dementia) areas had not completed all scheduled audits for medication management, mini clinical record audit, pressure injury prevention management, wound and skin care, falls management and neurological observations. | Ensure the internal audit schedule is completed as planned. | PA Low | In Progress | |
| A medication management system shall be implemented appropriate to the scope of the service. | i). Effectiveness of PRN medication was not consistently documented in five of 12 medication files reviewed. ii). Two of 12 three monthly medication reviews by the general practitioner were overdue at the time of the audit. iii). Weekly controlled drug medication checks have not been completed consistently in the hospital wing. iv). Five of 12 resident medications files evidenced photographs which had not been reviewed for between one and two years. | i). Ensure the effectiveness of PRN medication is documented. ii). Ensure medical reviews are completed and documented three monthly. iii). Ensure controlled drug stock medication checks are completed as per legislative requirements. iv). Ensure resident photographs on medication charts are current as per policy. | 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 | i). Three of nine residents utilising restraint did not have the use of restraint documented in the LTCP. ii). The LTCP of one dementia resident utilising a body suit restraint did not have interventions documented for toileting, behaviours, activities of daily living or management strategies for restraint application and monitoring. iii). Two of eight residents utilising restraint did not evidence approval or assessment documentation. iv). One hospital resident with a history of frequent falls | i-v). Ensure LTCPs have detailed interventions documented to provide guidance to care staff on care management. | PA Moderate | In Progress | |
| Service providers shall understand and comply with statutory and regulatory obligations in relation to essential notification reporting. | Three of 13 current pressure injuries were not reported through to HQSC as required. | Ensure all adverse events are reported through the incident reporting system to effectively respond to risks. | PA Low | 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 | i). Eight of nine residents utilising restraint did not evidence check and release as per policy. ii). Eight of eight residents on repositioning charts did not evidence completion as per policy. iii). One resident with chronic wounds on both legs had both wounds documented on one chart. iv). Five of eight wounds reviewed did not evidence dressings were completed as scheduled. v). Five of six pressure injuries reviewed were not correctly staged in the wound log. vi). Four of six neurological obse | i-ii). Ensure restraint and repositioning charts are completed as scheduled. iii-v). Ensure wounds are documented on individual wound management plans, staged correctly and that dressings are completed as scheduled. vi). Ensure neurological observations are completed as per policy. | PA Moderate | 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 | Evaluation of progress towards goals was not included in three of six, six monthly LTCP reviews (one hospital and two dementia). | Ensure evaluations document progress towards care plan goals. | PA Low | In Progress | |
| A process shall be implemented to identify, record, and communicate people’s medicinerelated allergies or sensitivities and respond appropriately to adverse events. | Medicine allergies were not documented on three of 12 medication charts reviewed | Ensure medication allergies are identified and documented on medication charts. | 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: Surveillance Audit
Audit date:
Audit type: Partial Provisional Audit; Certification Audit
Audit date:
Audit type: Surveillance Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Surveillance Audit
