Brittany House Residential Care
Profile & contact details
|Premises name||Brittany House Residential Care|
|Address||221 Wolseley St Mayfair Hastings 4122|
|Service types||Geriatric, Medical, Physical, Rest home care|
|Certification/licence name||TerraNova Homes & Care Limited - Brittany Residential Care|
|Current auditor||Health and Disability Auditing New Zealand Limited|
|End date of current certificate/licence||20 August 2020|
|Certification period||36 months|
|Provider name||TerraNova Homes & Care Limited|
|Street address||Unit 7, Building 2 1 William Pickering Drive Albany Auckalnd 0638|
|Post address||PO Box 37512 Parnell Auckland 1151|
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: 24 January 2019
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|An appropriate 'call system' is available to summon assistance when required.||i) Call bells were not evidenced to be within residents reach in eleven out of sixty-two resident bedrooms and bathrooms (six resident bathrooms upstairs and five bedrooms downstairs). Since the audit the maintenance man has been working through addressing this and ensuring all call bells have extension calls that now can be reached by residents. ii) The call bell system on the ground floor is not able to alert staff that emergency assistance is required. Both staff working on the ground floo… (this text has been trimmed due to space limits).||(i-ii) Ensure that call bells are accessible and placed within residents reach and that call bells are able to alert of an emergency situation requiring urgent assistance.||PA Low||Reporting Complete||01/12/2017|
|Consumers have a right to full and frank information and open disclosure from service providers.||Seven of fifteen resident related incident reports (and progress notes) reviewed did not document contact with family regarding the incidents.||Ensure that accident/incident forms are fully completed to indicate that family have been informed of the incident.||PA Low||Reporting Complete||01/12/2017|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||Complaints received prior to the manager taking up the role were not able to be accessed by the service as these complaints were not logged onto the complaints register. This included a Health and Disability complaint.||Ensure that all complaints are logged onto the complaints register and are available for review by the service.||PA Low||Reporting Complete||28/05/2019|
|All records pertaining to individual consumer service delivery are integrated.||There is no documented process for the retrieval of resident and service information held on the electronic register should there be a system outage.||Ensure there is a documented process, that is known by the service management team, for the retrieval of all resident information and data should there be a system outage and that resident information is readily available.||PA Negligible||Reporting Complete||28/05/2019|
|An appropriate 'call system' is available to summon assistance when required.||Two residents were heard calling out by the auditor, both did not have bells within reach, this was rectified on the day of audit.||Ensure that resident have access to a call system||PA Moderate||Reporting Complete||28/05/2019|
|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.||(i)In the downstairs treatment room, the medication fridge temperature has not consistently recorded daily.||Ensure that fridge temperatures are monitored and documented.||PA Low||Reporting Complete||28/05/2019|
|The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.||(i)Neurological observations were not documented as completed post unwitnessed falls for two of two falls that required neurological observations. (ii) Three of six wound care plans did not document the timeframes for dressing/evaluation and evaluations were not always fully completed. (iii) One hospital resident with a syringe driver did not have consistent monitoring for break-through pain. (iv) One hospital level resident who had a history of wandering had this documented in the care plan … (this text has been trimmed due to space limits).||(i)Ensure that Neurological observations are completed according to policy. (ii) Ensure that wound care plans document the timeframes for dressing/ evaluation and that evaluations are fully documented. (iii) - (iv) Ensure that monitoring is documented as per care plan.||PA Moderate||Reporting Complete||28/05/2019|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||An annual resident and relative satisfaction survey has not been conducted since 2016.||Ensure that an annual resident and relative satisfaction survey is conducted.||PA Low||Reporting Complete||13/08/2019|
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: 24 January 2019
Audit type:Surveillance Audit
- Brittany House Residential Care - Jan 2019 (docx, 36.46 KB)
- Brittany House Residential Care - Jan 2019 (pdf, 144.47 KB)
Audit type:Certification Audit
- Brittany House Residential Care - Jun 2017 (docx, 53.18 KB)
- Brittany House Residential Care - Jun 2017 (pdf, 185.98 KB)
Audit type:Surveillance Audit
- Brittany House Residential Care - Sep 2015 (docx, 35.89 KB)
- Brittany House Residential Care - Sep 2015 (pdf, 141.89 KB)
Audit type:Certification Audit