Birchleigh Residential Care Centre

Profile & contact details

Premises details
Premises nameBirchleigh Residential Care Centre
Address 77 Doon Street Mosgiel 9024
Total beds83
Service typesGeriatric, Medical, Dementia care, Rest home care
Certification/licence details
Certification/licence nameBirchleigh Management Limited - Birchleigh Residential Care Centre
Current auditorBSI Group New Zealand Ltd
End date of current certificate/licence07 July 2026
Certification period36 months
Provider details
Provider nameBirchleigh Management Limited
Street address 77 Doon Street Mosgiel 9024
Post addressPO Box 328 Mosgiel 9053

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: 02 May 2023

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate 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 LowReporting Complete06/12/2023
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 LowReporting Complete06/12/2023
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… (this text has been trimmed due to space limits).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 LowReporting Complete06/12/2023
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… (this text has been trimmed due to space limits).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 LowReporting Complete06/12/2023
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 ModerateReporting Complete06/12/2023

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.

Back to top