Golden Bay Community Health

Profile & contact details

Premises details
Premises nameGolden Bay Community Health
Address 10 Central Takaka Road Takaka 7183
Total beds29
Service typesRest home care, Geriatric, Maternity, Medical
Certification/licence details
Certification/licence nameNelson Bays Primary Health Trust - Golden Bay Community Health
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence21 May 2019
Certification period36 months
Provider details
Provider nameNelson Bays Primary Health Trust
Street address 10 Central Takaka Road Takaka 7183
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: 11 April 2016

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
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.(1) Oxygen therapy has not been prescribed for two hospital residents that have been assessed as requiring oxygen, (2) Five of six eye drops in use have not been dated on opening. (3) Maternity service: Review of the medication charts identified missing documentation with prescribing/dispensing and documentation requirements; (i) Two of ten files did not have the time of administrating the medication; (ii) Two of ten files did not have the signature of the prescriber; (iii) Two of ten files… (this text has been trimmed due to space limits).(1) Ensure the use of oxygen is prescribed ; (2) ensure all eye drops are dated on opening; (3) Maternity service: Ensure all medications are prescribed correctly including dosage, time of administration, prescriber’s signature, route of medication and indication for medication. Ensure medication charts are used if prescribing and dispensing medications for mother or baby while inpatients in the facility. PA ModerateIn 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.Maternity service: Not all policies, guidelines and protocols for the maternity service have had their 1-3 yearly review. Maternity service: Ensure all maternity policies, guidelines and protocols have a regular and timely review process. PA LowReporting Complete09/05/2017
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.One hospital resident admitted for permanent care under another contract (ACC) did not have a long-term care plan completed within twenty-one days of admission. Ensure long-term care plans are developed within 21 days of admission for all new admissions. PA LowReporting Complete09/05/2017
All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines.End cooked temperatures have not been taken or recorded for meats/poultry as per protocol. Ensure end cooked temperatures for meat/poultry are taken and recorded as per protocol. PA LowReporting Complete09/05/2017
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.Accident/incident data is not able to be collated to identify trends and corrective actions and therefore not documented in meeting minutes. Quality data including accident/incidents, infection control events and outcomes of internal audits is not linked into the meeting minutes or quality system. Ensure there is documented evidence of discussion around quality data, trends and analysis PA LowReporting Complete20/07/2017
Information is entered into the consumer information management system in an accurate and timely manner, appropriate to the service type and setting.All labour and birth information was not documented within the clinical notes and a labour and birth summary was not generated and placed within the client records. Ensure all labour and birth information is documented within the clinical notes and a labour and birth summary is completed and added to the file. PA LowReporting Complete20/07/2017
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.(1) Long-term care plans for three residents did not reflect the current needs for; (i) one hospital resident with high risk of pressure injury did not have pressure injury prevention strategies documented. The same resident did not have any alert on the file for identified risk of choking and the use of oxygen has not been identified in the care plan, (ii) a rest home resident on oxygen did not have the criteria documented in the care plan for the administration of oxygen. (iii) There were no … (this text has been trimmed due to space limits).Ensure care plans reflect the resident’s current health status. PA LowReporting Complete13/09/2017
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.There was no documentation in the progress notes or electronic medication system of the effectiveness of ‘as required pain’ relief for three residents (two hospital and one rest home). Ensure the effectiveness of ‘as required’ pain relief is documented. PA LowReporting Complete13/09/2017

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: 11 April 2016

Audit type:Certification Audit

Audit date: 13 August 2013

Audit type:Verification Audit

Audit date: 28 May 2013

Audit type:Verification Audit

Audit date: 18 March 2013

Audit type:Certification Audit; Verification Audit

Audit date: 03 April 2012

Audit type:Provisional Audit

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