Brittany House Residential Care

Profile & contact details

Premises details
Premises name	Brittany House Residential Care
Address	221 Wolseley St Mayfair Hastings 4122
Total beds	62
Service types	Physical, Rest home care, Geriatric, Medical

Certification/licence details
Certification/licence name	TerraNova Homes & Care Limited - Brittany House Residential Care
Current auditor	Health and Disability Auditing New Zealand Limited
End date of current certificate/licence	20 August 2023
Certification period	24 months

Provider details
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: 08 June 2021

Outcome required	Found at audit	Action required	Risk rating	Action status	Date action reported complete
The service is able to demonstrate that written consent is obtained where required.	Two (hospital including one respite) out of eight resident files reviewed did not have a signed consent.	Ensure all residents have given informed consent.	PA Low	Reporting Complete	10/08/2021
All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.	(i) Fridge and freezer temperatures are not recorded accurately as per policy and the temperatures of one fridge are not being monitored. (ii) Corrective actions are not put in place when temperatures are over the normal as per policy.	(i) Record fridge and freezer temperatures accurately including taking temperatures for one fridge where temperatures have not been previously monitored. (ii) Develop corrective action plans when temperatures are not within normal range and sign off evidence of resolution.	PA Low	Reporting Complete	10/08/2021
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.	(i) Training has not been accessed by a significant numbers of relevant staff in 2020 and 2021. (ii) Managers were not able to confirm numbers of caregiving staff who had completed Careerforce training. (iii) The infection control resource nurse has not yet completed annual training in infection control.	(i) Ensure that training is provided and attended by staff as per the training plan. (ii) Collate statistics around caregivers who have completed Careerforce training. (ii) Ensure that the infection control resource nurse completes annual training in infection control.	PA Low	Reporting Complete	10/08/2021
Consumers who have additional or modified nutritional requirements or special diets have these needs met.	Dietary assessments are not kept updated for kitchen staff to view and kitchen staff are not informed of residents who are losing weight.	Ensure that kitchen staff have accurate information around each resident’s dietary needs.	PA Moderate	Reporting Complete	10/08/2021
The service respects the physical, visual, auditory, and personal privacy of the consumer and their belongings at all times.	There are two communal shower/toilet blocks that potentially do not afford privacy for residents using them at all times.	Ensure that communal shower/toilet blocks allow for privacy for residents using them at all times.	PA Low	Reporting Complete	10/08/2021
Consumers have a right to full and frank information and open disclosure from service providers.	Six of fifteen incident reports did not evidence family contact following the incident being reported.	Ensure that family are contacted in a timely manner to inform them of the incident	PA Low	Reporting Complete	10/08/2021
Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.	The menu has not been updated since March 2017 and it currently does not reflect what is being provided.	Review the menu to ensure that it meets resident needs and reflects what is being provided.	PA Low	Reporting Complete	10/08/2021
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.	Corrective action plans are not documented when issues are raised in audit reports, food service audits, or satisfaction surveys or documented with evidence of resolution, and issues are not closed out when these are raised in meetings.	Ensure that there are corrective action plans documented when issues are raised in audit reports and evidence of resolution of issues against corrective actions when addressed including those raised in meetings.	PA Moderate	Reporting Complete	10/08/2021
All buildings, plant, and equipment comply with legislation.	Hot water temperature has not been well controlled over previous six months, despite monthly water temperature testing they continue to be above 45 degrees. The service undertook an analysis of hot water issues and an action plan has been put in place. At the time of audit this action plan, which included a plumber, had just commenced.	Ensure that hot water temperature issues are addressed in a timely fashion.	PA Low	Reporting Complete	10/08/2021
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.	(i) One hospital level resident for daily PEG Feed monitoring did not have monitoring documentation completed. (ii) One hospital resident with an identified pressure injury did not have the required repositioning consistently documented. (iii) Two hospital residents with catheters did not have daily fluid balance charts completed consistently. (iv). Eleven of eleven incident forms were sampled where the resident had experienced an unwitnessed fall. RN assessment was documented following… (this text has been trimmed due to space limits).	(i)-(iii). Ensure resident monitoring charts are consistently and comprehensively completed. (iv). Ensure that neurological observations are recorded for unwitnessed falls as per policy.	PA Moderate	Reporting Complete	10/08/2021
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.	(i) Four (three rest home, one hospital) of eight files sampled did not include interventions or interventions were not documented in sufficient detail to guide the care staff in the management of cellulitis, diabetic emergencies, enteral feeding and falls prevention. (ii) Two (hospital) of eight resident care plans sampled did not detail the need or rationale for the crushing of medication in line with the residents’ medication charts.	(i) Ensure that care plan interventions are documented in sufficient detail to guide the care staff. (ii) Ensure that details around the need for, or rationale for the crushing of medication in line with the residents’ medication charts is documented in care plans.	PA Moderate	Reporting Complete	06/12/2021
New service providers receive an orientation/induction programme that covers the essential components of the service provided.	Orientation is not documented as being completed in five or eight staff files reviewed.	Ensure that all staff have documentation in their staff file that confirms orientation has been completed.	PA Low	Reporting Complete	06/12/2021

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.

Audit reports

Audit date: 08 June 2021

Audit type:Certification Audit

Audit date: 24 January 2019

Audit type:Surveillance Audit

Audit date: 12 June 2017

Audit type:Certification Audit

Audit date: 10 September 2015

Audit type:Surveillance Audit

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