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: 27 March 2018
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.||A resident administered medication by facility staff did not have a supporting prescription provided by a GP.||To ensure that all medications administered to residents at the facility have evidence of a supporting prescription to meet legislation and best medicine guidelines.||PA High||Reporting Complete||12/07/2018|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||Two complaints raised at the six monthly family meetings are not documented in the complaints register. One relates to loss of personal belongings and one is about a resident who enters other residents’ rooms.||Provide evidence that all complaints are documented in the complaints register.||PA Moderate||Reporting Complete||22/08/2018|
|Service providers responsible for medicine management are competent to perform the function for each stage they manage.||No all staff administering medication to residents had completed and/or had an up to date medication competency assessment.||Provide evidence that all staff administering medication are competent to do so.||PA High||Reporting Complete||04/09/2018|
|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 administration processes were not undertaken in accordance with the organisational policy and good practice in relation to administration, storing, checking of medication and documentation of fridge temperatures.||Provide evidence of safe medication management.||PA High||Reporting Complete||04/09/2018|
|The organisation has a quality and risk management system which is understood and implemented by service providers.||Staff meeting minutes do not include quality improvement data information and staff knowledge of the quality and risk systems in place was limited. No documented results could be found relating to internal audits being undertaken for 2017-2018. Staff have limited understanding of the quality and risk management system and are unaware of collated monthly quality data findings.||Provide evidence that quality and risk management systems are fully implemented to meet policy requirements and that staff have a better understanding of quality and risk processes that operate throughout the organisation including knowledge of collective quality data information.||PA Low||Reporting Complete||19/11/2018|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||Quality data evaluation outcomes for corrective actions put in place are not shared with all staff.||Provide evidence that all quality data collected is shared with staff along with documentation of evaluation of corrective action outcomes.||PA Low||Reporting Complete||19/11/2018|
|All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.||The kitchen requires some maintenance and the cleaning schedule was not accurately signed as completed.||Provide evidence that the cleaning schedule is maintained daily and signed in acknowledgement of the work completed. There is a plan in place detailing maintenance required and this is completed as needed.||PA Low||Reporting Complete||19/11/2018|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Two of seven staff files reviewed did not contain documented orientation records. One staff member’s annual appraisal was overdue by four months.||Provide evidence that all staff have completed an orientation and that the schedule of staff appraisal dates is implemented.||PA Low||Reporting Complete||30/01/2019|
|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.||Not all residents were admitted to the facility by a registered nurse or GP within required time frames. Not all residents had supporting management plans for wound management or weight loss. Not all residents had evidence of documentation for example resuscitation, the required notification of level of care or admission agreement which included consents.||To provide evidence that each stage of service provision (assessment, planning, provision, evaluation, review) are completed within timeframes to meet contractual, legislative requirements and good practice.||PA High||Reporting Complete||12/04/2019|
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: 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
- Briargate Dementia Care Unit - Jun 2015 (docx, 31.69 KB)
- Briargate Dementia Care Unit - Jun 2015 (pdf, 127.78 KB)
Audit type:Certification Audit