Briargate Dementia Care Unit
Profile & contact details
|Premises name||Briargate Dementia Care Unit|
|Address||21 Anne McLean Drive Bayview Auckland 0629|
|Service types||Dementia care|
|Certification/licence name||Briargate Healthcare Limited - Briargate Dementia Care Unit|
|Current auditor||The DAA Group Limited|
|End date of current certificate/licence||29 October 2021|
|Certification period||24 months|
|Provider name||Briargate Healthcare Limited|
|Street address||21 Anne McLean Drive Bayview Auckland 0629|
|Post address||24B Kingsview Road Mount Eden Auckland 1024|
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: 15 October 2020
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Key components of service delivery shall be explicitly linked to the quality management system.||There is limited evidence that key components of service delivery are being explicitly linked to the quality management system as is indicated in policy.||Ensure the key components of service delivery are reported to management and the owner/director so the information can be explicitly linked to the quality management system as described in policy.||PA Low||Reporting Complete||02/06/2020|
|Service providers responsible for medicine management are competent to perform the function for each stage they manage.||Practical medication competencies of staff administering medication were not verified.||Ensure practical medication assessments are included in the annual competency programme.||PA Moderate||Reporting Complete||11/11/2019|
|Consumers are provided with safe and accessible external areas that meet their needs.||The only secure outdoor space for resident use has no furnishings or shaded areas.||Ensure residents are provided with safe and accessible external areas that meet their needs.||PA Low||Reporting Complete||11/11/2019|
|A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines.||Medication entries reviewed did not have documented evidence of effectiveness of PRN medication administered and the PRN medications were not being monitored by the registered nurses.||Provide evidence that the effectiveness of PRN medication administered is documented after use and that the registered nurses monitor the use of PRN medicines.||PA Moderate||Reporting Complete||11/11/2019|
|The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.||Not all senior staff are aware of their statutory or regulatory obligations in relation to essential notification reporting.||Ensure all senior staff are aware of their obligations related to essential notification reporting.||PA Low||Reporting Complete||11/11/2019|
|There are adequate numbers of accessible toilets/showers/bathing facilities conveniently located and in close proximity to each service area to meet the needs of consumers. This excludes any toilets/showers/bathing facilities designated for service providers or visitor use.||One of the three showers is being renovated and it is inoperable. Staff stated this had been in a state of refurbishment for a ‘couple of months’.||Ensure shower refurbishment is completed.||PA Low||Reporting Complete||11/11/2019|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||There was no evidence of an activities programme being developed and implemented since April 2019 for the residents at this facility. The diversional therapist who is on arranged leave was brought in to work on the day of the audit. Residents have been unable to access outdoors for approximately three weeks while an external deck area has been re-built. (Refer 184.108.40.206) No activities were planned for residents while this was occurring and is yet to be completed.||An activities programme is developed and implemented to cover while the DT is on leave suitable for residents to participate in as able. The programme is to include outside activities while the building project is occurring.||PA High||Reporting Complete||19/11/2019|
|Entry criteria, assessment, and entry screening processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies.||Two residents have no evidence of an assessment for secure dementia care.||Ensure all residents have an appropriate needs assessment for secure dementia care services.||PA High||Reporting Complete||19/11/2019|
|Consumers are kept safe and are not subjected to, or at risk of, abuse and/or neglect.||Staff education has not been provided to staff in relation to abuse and/or neglect to enable staff to be aware of their responsibilities in regard to this and to keep residents safe at all times.||Ensure all staff have been provided with education in relation to abuse and/or neglect as per the contract and standard requirements.||PA Low||Reporting Complete||27/11/2019|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||No information was available to evidence the status of the Food Safety Plan. An audit was completed on the 22 May 2019 with recommendations to be actioned.||Provide evidence of the food control plan requirements being completed and a copy of the food control plan.||PA Low||Reporting Complete||27/11/2019|
|The organisation is managed by a suitably qualified and/or experienced person with authority, accountability, and responsibility for the provision of services.||The facility manager had no handover for the role she is undertaking and is does not have a clear understanding of all her responsibilities related to the provision of services as set out in her job description.||Ensure the facility is managed by a suitably qualified or experienced person who understands their responsibilities related to the provision of services.||PA Moderate||Reporting Complete||29/01/2020|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Quality data is collected and collated but inconsistently analysed, evaluated and communicated. Staff meeting minutes showed that quality data is not reported at monthly meetings. There has been a monthly analysis of infection control data findings undertaken but the data has not been shared with staff or management. No documented analysis or evaluation of other quality data results could be found from January to May 2019. Data for June and July has a documented analysis but is yet to be evaluat… (this text has been trimmed due to space limits).||Provide evidence that all quality data collected is analysed and evaluated and that the results are communicated to staff, management and families/EPOA.||PA Moderate||Reporting Complete||29/01/2020|
|A process to measure achievement against the quality and risk management plan is implemented.||Internal audits are identified in policy as a process used to measure achievement against the quality and risk management plan. However, no internal audit results were able to be located from January 2019 to May 2019 making it difficult to measure what achievements have been made.||Ensure the documented internal audit process is maintained and results are used to assist the identification of measured achievement against the quality and risk management plan as identified in policy.||PA Low||Reporting Complete||29/01/2020|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Corrective actions are inconsistently documented and the correct form, as identified in policy, is not being used.||Ensure that all corrective actions are documented as required in policy using a unified form, so all staff understand what is required.||PA Low||Reporting Complete||29/01/2020|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||The facility manager who was employed in November 2018 and who changed roles in April 2019 has not completed an orientation.||Ensure all staff have an orientation to the position/s they currently hold.||PA Low||Reporting Complete||29/01/2020|
|Results of surveillance, conclusions, and specific recommendations to assist in achieving infection reduction and prevention outcomes are acted upon, evaluated, and reported to relevant personnel and management in a timely manner.||The infection control RN has been collecting and collating required infection control data, but this is not being reported as per the policy and processes documented. No reporting has occurred since 22 January 2019.||The infection control RN reports all relevant surveillance information to management and this is presented and addressed at the monthly quality and staff meetings.||PA Low||Reporting Complete||29/01/2020|
|The service develops and implements policies and procedures that are aligned with current good practice and service delivery, meet the requirements of legislation, and are reviewed at regular intervals as defined by policy.||What is stated in policy is not consistently implemented as some policies have remained generic and not been personalised to the service.||Ensure policies are personalised to the Briargate Dementia Care service and consistently implemented to ensure service delivery meets current good practice.||PA Low||Reporting Complete||02/03/2020|
|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.||Four of six residents’ files reviewed had no documentation to show incidents or accidents were reported to family members as is required in the open disclosure policy. One of the three different incident forms being used did not have any area to identify family needed to be informed. No evidence was found that information related to corrective actions are used as an opportunity to improve service delivery.||Ensure all adverse event information that identifies a service shortfall is used as an opportunity to improve overall service delivery and that documentation identifies if family have been informed.||PA Low||Reporting Complete||02/03/2020|
|All records are legible and the name and designation of the service provider is identifiable.||All records evidenced documents that were not labelled or documented with the name of the resident and/or the national health index number (NHI) is not documented on each page of the individual resident records as required. There was a storage room for archived resident records that was not easily accessible and there was no system in place for tracking and retrieving archived residents’ records as and when needed.||All residents’ records are accessible, identifiable and a system is developed and implemented for the retrieval of records as required.||PA Low||Reporting Complete||02/03/2020|
|The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.||Policy is not being met in regard to regular quality reviews and reports going to the owner/directors so that information can be used to establish if set goals are being met.||Provide evidence that regular reviews are undertaken to meet policy requirements so goals can be reviewed.||PA Low||Reporting Complete||02/06/2020|
|The organisation has a quality and risk management system which is understood and implemented by service providers.||The organisation’s quality and risk management system is not fully implemented as identified in policy. Quality data is not presented for quarterly management review or the staff meetings.||Ensure policy is followed related to the implementation of reporting quality data at both management review meetings and staff meetings.||PA Low||Reporting Complete||02/06/2020|
|There is a document control system to manage the policies and procedures. This system shall ensure documents are approved, up to date, available to service providers and managed to preclude the use of obsolete documents.||Documents are not managed to preclude the use of obsolete documents. Senior staff are unsure of the correct form to be used.||Ensure obsolete documents are removed and that staff are aware of and only use the current documents as per policy.||PA Low||Reporting Complete||02/06/2020|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||The education calendar for 2019 has not been followed. No education was presented from January 2019 to May 2019. Not all care staff have commenced required dementia training to meet contractual requirements.||Ensure regular staff training and education is ongoing and that the documented education occurs consistently. Provide evidence that care staff who have worked at the facility for over six months have commenced dementia series training to meet contractual requirements.||PA Low||Reporting Complete||02/06/2020|
|The responsibility for infection control is clearly defined and there are clear lines of accountability for infection control matters in the organisation leading to the governing body and/or senior management.||The infection prevention and control programme was reviewed 22 January 2019 but has not been implemented since that date. The IC RN is not informed of the job description available to guide this role. Meeting minutes do not include infection control on the agenda and no infection control committee has been arranged for this year.||Ensure the responsibility for infection control is clearly defined and that the RN is well informed of the role of ICN. Ensure there are clear lines of accountability for infection control matters that are reported to management appropriately and to staff at staff meetings and minutes are maintained.||PA Low||Reporting Complete||02/06/2020|
|There are written policies and procedures for the prevention and control of infection which comply with relevant legislation and current accepted good practice.||The policy describes the IC programme which is supported by use of a reference infection control manual to guide good practice. The manual reviewed was not current and is dated 2009.||Ensure the reference infection control manual to guide good practice is reviewed and updated to guide staff as per policy.||PA Low||Reporting Complete||02/06/2020|
|Infection control education is provided by a suitably qualified person who maintains their knowledge of current practice.||The infection control education for staff has not been provided since January 2019 and the designated RN for infection control has not completed any relevant training for this role.||Ensure the designated RN for infection control has completed infection prevention and control education relevant to this role and that infection control education is provided to staff as required.||PA Low||Reporting Complete||02/06/2020|
|Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is undertaken by suitably qualified and/or experienced service providers who are competent to perform the function.||The interRAI re-assessments are completed; however, the care plans are not being reviewed and updated in a timely manner (eg, two to three months after the interRAI is completed).||Ensure the care plans are updated after the interRAI assessments have been completed to reflect any changes required.||PA Low||Reporting Complete||03/08/2020|
|Entry criteria, assessment, and entry screening processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies.||Records detailing the outcomes of the Needs Assessment and Service Coordination (NASC)/specialists referral process was not able to be verified for two residents whose files were reviewed. A completed admission agreement and consent form could not be located for the resident audited using tracer methodology who was receiving dementia level of care. Admission agreements were not able to be located for three other residents.||Ensure the outcome of the Needs Assessment and Service Coordination outcomes /specialist referral are readily available, along with admission agreements and consent forms for all residents receiving care.||PA Moderate||In Progress|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||Plans have not been developed to describe how the behaviour/routine of individual residents are best managed over a 24 hour period, including identification of individualised diversion, motivation and recreational therapy as required by the aged related residential care contract for residents assessed as requiring dementia level care.||Individualised plans are developed that describe how the behaviour/routine for each resident receiving dementia level care is best managed over a 24-hour period, including identification of individualised diversion, motivation and recreational therapy.||PA Low||In Progress|
The outcome required by the Health and Disability Services Standards.
Found at audit
The issue that was found when the rest home was audited.
The action necessary to fix the issue, as decided by the auditor.
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.
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.
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 reportsAudit date: 15 October 2020
Audit type:Surveillance AuditAudit date: 27 March 2018
Audit type:Surveillance Audit
- Briargate Dementia Care Unit - Mar 2018 (docx, 37.22 KB)
- Briargate Dementia Care Unit - Mar 2018 (pdf, 145.09 KB)
Audit type:Certification Audit
- Briargate Dementia Care Unit - Aug 2016 (docx, 45.55 KB)
- Briargate Dementia Care Unit - Aug 2016 (pdf, 176.98 KB)
Audit type:Surveillance Audit