Brylyn Residential Care

Profile & contact details

Premises details
Premises nameBrylyn Residential Care
Address 200 Te Kowhai Road RD 8 Hamilton 3288
Total beds34
Service typesGeriatric, Rest home care
Certification/licence details
Certification/licence namePrasad Family Foundation Limited
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence19 April 2019
Certification period24 months
Provider details
Provider namePrasad Family Foundation Limited
Street address 71 Ashby Avenue St Heliers Auckland 1071
Post address

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: 13 February 2017

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Protective equipment and clothing appropriate to the risks involved when handling waste or hazardous substances is provided and used by service providers.Aprons and visors were not available at the point of use in the sluice room and laundry sluice area. Ensure personal protective wear is available at the point of use. PA ModerateIn Progress
A process to measure achievement against the quality and risk management plan is implemented.Not all internal audits have been completed as per the audit schedule. Ensure that the monitoring schedule is fully implemented. PA LowIn Progress
Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.The facility is not covered by a minimum of one staff member on each shift who holds a current first aid certificate. Ensure there is a minimum of one staff with a current first aid/CPR certificate available at all times. PA LowIn Progress
The appointment of appropriate service providers to safely meet the needs of consumers.Three staff that were not born in New Zealand did not have copies of visa and work permit documentation on file. Ensure that all staff working at the facility are legally entitled to do so, and a copy of relevant immigration documentation is kept on staff files. PA ModerateIn Progress
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.i) Corrective action plans are not consistently documented where opportunities for improvements are identified. ii) Not all corrective action plans are evaluated and signed off when completed. iii) A corrective action plan has not been documented or implemented to address the areas requiring improvement noted in the recent resident survey. i-iii) Ensure that corrective actions plans are documented where opportunities for improvement are noted and the corrective action plans are then implemented, reviewed and signed off once completed. PA LowIn Progress
Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome.Two of two acute care plans had not been evaluated as either resolved or updated as an ongoing problem. Ensure acute care plans are evaluated within a timely manner. PA LowIn Progress
Service providers responsible for medicine management are competent to perform the function for each stage they manage.(i) The nurse manager/registered nurse is responsible for assessing staff for medication competency but has not completed the annual competency. Two RNs and three caregivers also have not completed the annual medication competency. (ii) There is no documented evidence of clinical staff attending annual medication education. (i) Ensure medication competencies are completed annually. (ii) Ensure clinical staff attend medication education annually. PA ModerateIn Progress
New service providers receive an orientation/induction programme that covers the essential components of the service provided.Five of six files sampled had no evidence of completion of the orientation programme. Ensure that the required orientation/induction programme is completed by all staff and evidence of this is kept on staff files. PA ModerateIn Progress
Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include: (a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk; (b) A process that addresses/treats the risks associated with service provision is developed and im… (this text has been trimmed due to space limits).i) The nurse manager has not had any training in Health and Safety management. ii) Staff have not had any training or information about the changes to the Health and Safety legislation that occurred in April 2016. iii) Not all sections of the hazard management form currently in use are fully completed. iv) Where improvements are required for the management of hazards, not all corrective action plans are documented or reviewed for effectiveness. v) Not all staff accidents are logged on the … (this text has been trimmed due to space limits).i) Ensure all staff receive regular training in Health and Safety. ii) Ensure the nurse manager/registered nurse completes training in Health and Safety management. iii-iv) Ensure that all aspects of the health and safety management system are fully implemented. PA ModerateIn Progress
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.i) There was no documented education planner for 2016, and no documented education plan for 2017. ii) Not all staff currently employed have received training in abuse and neglect prevention, cultural awareness, advocacy services and the code of rights, management of wounds and pressure injuries, and infection control. iii) Not all staff have completed the required competencies. iv) The Infection control coordinator has not completed education in relation to infection control. v) Not all st… (this text has been trimmed due to space limits).i-ii) Ensure that the annual education planner is fully implemented and that education and training is provided to meet the requirements of the health and disability sector standards and the aged related residential care agreement. iii) Ensure that all staff complete the required competencies. iv) Ensure the IC Coordinator completes the required education in relation to IC. v) Ensure that all staff who work in the kitchen have completed food safety training. vi) Ensure that performance rev… (this text has been trimmed due to space limits).PA ModerateIn Progress
Where required by legislation there is an approved evacuation plan.Six monthly trail evacuations could not be evidenced. Ensure that six monthly trail evacuations are consistently held and the required documentation is completed. PA ModerateIn Progress
An appropriate 'call system' is available to summon assistance when required.i) Eight of thirty-two resident bedrooms had call points in the wall with no cord attached and the residents could not reach the switch easily from the bed. ii) One resident interviewed advised that they could not use the call bell provided because of their health issues. i-ii) Ensure that all residents have access to a call bell they can operate. PA ModerateIn Progress
Information of a private or personal nature is maintained in a secure manner that is not publicly accessible or observable.i) Information of a private or personal nature is not stored securely in the nurse manager/registered nurse’s office. ii) The archived resident information was not securely stored. iii) Names of residents on a shower list were displayed on a noticeboard that could be read by the public and/or other residents. i-ii) Ensure all resident information of a private or personal nature is maintained in a secure manner. iii) Ensure that resident information is not visible by other residents or the public PA LowIn Progress
Service providers follow a documented process for the safe and appropriate storage and disposal of waste, infectious or hazardous substances that complies with current legislation and territorial authority requirements.(i) Several chemical bottles were sighted in showers and toilets in the facility and the sluice room was found to be unlocked on several occasions throughout the audit. (ii) Two bottles of chemicals did not have manufacturer labels. (i) Ensure chemicals are stored safely. (ii) Ensure all chemical bottles have manufacturer labels. PA ModerateIn Progress
All buildings, plant, and equipment comply with legislation.(i) There were two electric beds with badly frayed cables to the hand remote controller. These had been missed during the annual electrical check. One bed was not in use. The maintenance person was called in to cover the cables with a safe covering and notify the electrical contractor. Electric wall heaters in resident rooms had not had an annual electrical check. (ii) The studio hallway carpet has damaged areas caused by carpet eating bugs, which has been treated. The dining room vinyl is … (this text has been trimmed due to space limits).(i) Ensure all resident and environmental equipment has an annual electrical safety check. (ii) Ensure flooring meets hygiene and safety standards. (iii) Ensure hand washing stations meet infection control standards. PA ModerateIn Progress
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.The admission agreement did not include all the contractual clauses around termination of the agreement and timeframe for refund of overpayments. Ensure the admission agreement aligns with the DHB contractual requirements. PA LowIn Progress
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.i) There are no policies and procedures documented for the operation of the laundry. ii) The Health and Safety policy has not been reviewed annually as required by the Health and Safety policy. iii) The pressure injury policy in use, does not reflect the MOH guidelines on the staging of pressure injures. i) Ensure that policies and procedures are documented to cover all aspects of the service. ii) Ensure that the policies and procedures are all reviewed within the timeframes required, and are updated as required. iii) Ensure the Pressure Injury policy reflects current best practice. PA LowIn Progress
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.(i) There is no documented process on how to review the organisational documents. (ii) There is no documented policy review schedule. (iii) There is no implemented process around communicating policy changes to staff. Ensure a document control process and system is documented and implemented. PA LowIn Progress
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.The InterRAI assessment tool had not been used for the six-monthly review of two residents (one rest home and one hospital level of care). Ensure the InterRAI assessment tool is used as part of the six-monthly review of the resident lifestyle plan. PA LowIn Progress
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.(i) There were no documented interventions for one rest home resident with a 3.5kg weight loss in one month and (ii) neurological observations had not been completed for three residents with unwitnessed falls. (i) Ensure interventions are implemented for residents with weight loss and (ii) complete neurological observations for unwitnessed falls. PA ModerateIn Progress
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.Four of five lifestyle plans (one hospital and three rest home) did not reflect the resident current interventions and needs/supports for the following; (i) One hospital resident with behaviours as reported in progress notes. (ii) Changes in behaviours and sleep pattern for one rest home resident with cognitive decline. (iii) Early warning signs and symptoms of declining mental health for one rest home resident as per the discharge summary. (iv) No pain management plan for one rest home residen… (this text has been trimmed due to space limits).Ensure lifestyle plans reflect the resident’s current needs/supports to meet the resident goals. Ensure that residents who identify with another culture have their cultural and spiritual needs documented in their care plan. Ensure that residents who identify as Māori have their cultural and spiritual needs documented in their care. PA ModerateIn Progress
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.i) Quality improvement data is not consistently trended and analysed to identify opportunities for improvement. ii) There is a lack of documented evidence to reflect quality improvement data is being communicated to staff. iii) The results of the resident satisfaction survey completed in December 2016 have not been communicated to the residents. iv) There is no audit scheduled for the review of wound management or pressure injury v) Where staff meetings have been held there is no evidence t… (this text has been trimmed due to space limits).i-iii) Ensure that all quality improvement data is trended and analysed and the results communicated to staff and residents where appropriate. iv) Ensure there is a scheduled review of the management of wound care and pressure injury management. v) Ensure that all relevant aspects of the quality management system are communicated to staff. PA LowIn Progress
There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.i) There are insufficient hours allocated to complete the operational management and leadership requirements of the role. ii) There are insufficient care staff allocated to resident cares on an afternoon shift between 1530 and 1830. i) Ensure that there are sufficient hours allocated to complete the operational requirements of the facility management role. ii) Ensure there are sufficient staff rostered on at all times to meet the needs of the residents. PA ModerateIn Progress
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.Three bottles of antibiotic stock had expired. Ensure all medications held are within the expiry dates. PA LowIn Progress

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. 

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 reports

Audit date: 13 February 2017

Audit type:Certification Audit

Audit date: 19 February 2016

Audit type:Surveillance Audit

Audit date: 23 February 2015

Audit type:Certification Audit

Audit date: 13 August 2014

Audit type:Surveillance Audit

Audit date: 20 January 2014

Audit type:Partial Provisional Audit

Audit date: 02 July 2013

Audit type:Surveillance Audit

Audit date: 22 February 2012

Audit type:Certification Audit

Audit date: 30 March 2011

Audit type:Surveillance Audit

Audit date: 11 March 2010

Audit type:Certification Audit

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