Brylyn Residential Care

Profile & contact details

Premises details
Premises nameBrylyn Residential Care
Address 200 Te Kowhai Road RD 8 Hamilton 3288
Total beds35
Service typesMedical, Geriatric, Rest home care
Certification/licence details
Certification/licence namePrasad Family Foundation Limited - Brylyn Residential Care
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence19 April 2022
Certification period36 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: 19 October 2020

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
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.The purchased policies are not yet rolled out to staff. Roll out the new policies and procedures with staff orientated to these prior to use. PA LowReporting Complete10/07/2019
All buildings, plant, and equipment comply with legislation.There were two nebuliser machines, one suction machine and two oxygen concentrators that do not have annual calibrations. Ensure all medical equipment is calibrated annually. PA ModerateReporting Complete10/07/2019
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.(i) The interRAI assessment tool had not been completed within 21-days of admission in three of four long-term resident files reviewed (two hospital and one rest home). (ii) Six-monthly interRAI and care plan evaluations had not been completed in two of four resident files (one rest home and one hospital level of care) requiring this. (i) Ensure the interRAI assessment is completed within 21-days of admission. (ii) Ensure the interRAI assessment and care plan evaluation is completed six monthly on all long-term residents. PA ModerateReporting Complete10/07/2019
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.Three of four long-term care plans reviewed did not include interventions and needs/supports for the following; (i) One rest home with challenging behaviour and indwelling urinary catheter as reported in progress notes. (ii) Two hospital residents with weight loss. Ensure care plans include interventions to support the resident’s current needs. PA ModerateReporting Complete15/07/2019
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.There is not a comprehensive evaluation of all domains of the care plan in four of four resident files reviewed who had been admitted for over six months. Ensure that the care plan is fully evaluated at the six-monthly review of the care plan. PA LowIn Progress
The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.The business plan and quality/risk management plans have not been reviewed at frequent intervals and annually prior to the new plans being developed. Ensure the business plan and quality/risk management are reviewed at frequent intervals and annually prior to the new plans being developed. PA LowIn Progress
A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.A corrective action plan has not been documented for the resident/family satisfaction survey completed in 2019. Document a corrective action plan for the resident/family satisfaction survey completed in 2019 and implement with evidence of resolution of issues. 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.(i) The initial assessment and care plan in one of the resident files reviewed was not dated. (ii) Three resident records at hospital level of care showed that the first interRAI had not been completed within 21 days. (iii) In four of the long-term files reviewed (two hospital and two rest home level of care including two who had been admitted in 2020), the long-term care plan had not been developed within 21 days following admission. (iv) The interRAI assessments have not been completed si… (this text has been trimmed due to space limits).(i) Ensure that initial assessments and care plans are dated and completed in a timely manner. (ii) Complete the first interRAI within 21 days following admission. (iii) Ensure that the initial long-term care plan is developed within 21 days following admission. (iv) Complete an interRAI re-assessment at six monthly intervals or earlier if health changes. (v) Ensure that the long-term plan is reviewed in a timely manner (i.e., after the interRAI has been completed). PA ModerateIn Progress
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.1. Four of the long-term care plans reviewed did not include interventions and needs/supports for the resident as identified through discussions with care staff and as identified through the assessment process. (i) There is one communal weight management plan documented for four residents with weight loss and this is only signed off by the HCA. The registered nurse interviewed stated that they look at the care plan as soon as it is completed (same day) however, while the registered nurse sig… (this text has been trimmed due to space limits).1. Ensure care plans include interventions to support the resident’s current needs. 2. Ensure that activities assessments/plans are reviewed alongside the review of the care plan. PA ModerateIn Progress
The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.There is a strong smell of urine in two of the hallways. Address the strong smell of urine in two of the hallways. PA LowIn Progress
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.Five of six incident forms for a resident with an unwitnessed fall or a fall with a head injury did not show that neurological observations are taken as per policy. Ensure that neurological observations are taken as per policy for any resident who has an unwitnessed fall or a fall with a head injury. PA ModerateIn Progress
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.(i). There is only some documentation of discussion of trends and corrective actions in the meeting minutes. (ii). Resolution of issues is not documented. (iii). The audit schedule has not been implemented in most of 2019 and 2020. (i).Ensure meeting minutes reflect discussion of trends and corrective actions. (ii). Ensure that issues are resolved with resolution documented. (iii). Ensure the audit schedule is implemented. PA ModerateIn 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.

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