Shelly Beach Dementia
Profile & contact details
|Premises name||Shelly Beach Dementia|
|Address||19 Shelly Beach Road Saint Marys Bay Auckland 1011|
|Service types||Dementia care|
|Certification/licence name||Graceful Home No.2 Limited - Shelly Beach Dementia|
|Current auditor||HealthShare Limited|
|End date of current certificate/licence||02 March 2018|
|Certification period||12 months|
|Provider name||Graceful Home No.2 Limited|
|Street address||30 Ranui Road Remuera Auckland 1050|
|Post address||PO Box 28188 Remuera Auckland 1541|
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 January 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|The needs, outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning.||Three interRAI assessments have not been completed at six monthly intervals. Three of the five files do not have a current interRAI assessment.||i) Ensure that interRAI assessments are completed at six monthly intervals. ii) Ensure that all residents have a current interRAI assessment.||PA Moderate||Reporting Complete||24/04/2017|
|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.||Three of five resident files reviewed include a care plan with plans in files last reviewed in May 2016.||Ensure that each resident has a service delivery care plan that describes the required support and interventions required to meet the needs of the resident.||PA Moderate||Reporting Complete||24/04/2017|
|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.||An initial assessment and initial plan is not completed on entry to the service for one resident who has entered the service in the past three months.||Ensure that an initial assessment and plan is documented on entry of the resident to the service.||PA Moderate||Reporting Complete||10/07/2017|
|Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.||The care plans are not always developed after an interRAI assessment has been completed. The care plans documented do not always reflect the needs of the resident including strategies to manage challenging behaviour.||Link care plans to needs identified through the interRAI assessments. Ensure that the care plans reflect strategies to manage needs including any challenging behaviour.||PA Moderate||Reporting Complete||10/07/2017|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||Resident activity plans do not detail interventions and a 24-hour activities plan for each resident is not documented. The existing plans are not dated and not completed in line with development and review of care plans. There is a lack of a qualified staff member providing the activities programme. There was a lack of activities observed to be provided on the day of audit and the activities coordinator states that they are often not able to spend time offering activities during the day. T… (this text has been trimmed due to space limits).||Ensure that a 24-hour activities plan with detailed interventions is developed and implemented for each resident. Ensure that each care plan is dated and developed in line with the review of the care plan. Ensure that there is a qualified staff member providing the activities programme. Provide activities for individual residents and for groups of residents that meet their needs. Ensure that documentation of the activities assessment and plan is completed alongside the review of the interRAI… (this text has been trimmed due to space limits).||PA Moderate||Reporting Complete||10/07/2017|
|The organisation identifies and implements appropriate security arrangements relevant to the consumer group and the setting.||There are two doors which potentially can prevent immediate access in the event of an emergency.||Ensure that all fire exits can be immediately accessed in the event of an emergency.||PA Moderate||Reporting Complete||29/11/2017|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||Two of five staff files do not have a current annual performance appraisal. Three staff have not had training in dementia and have been in the service for longer than six months for all.||Ensure that performance appraisals are completed annually. Ensure that new staff are enrolled in training in dementia after orientation.||PA Low||Reporting Complete||13/02/2018|
|The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the consumer/group.||The perimeter fence is potentially able to be scaled by a resident intent on leaving the premises.||Ensure that the site is secure and that residents are not able to scale perimeter fences.||PA Moderate||Reporting Complete||13/02/2018|
|An appropriate 'call system' is available to summon assistance when required.||Call bells are on the outside walls of bedrooms and may not be able to be accessed by staff, residents (noting that residents may not be likely to ring for help) or visitors when inside the bedroom. Staff state that they do not need to use the call bell system as staff are always present and the home is small enough for others to hear any calls for help.||Ensure that there is a call system that a person to call for help if inside a bedroom.||PA Low||Reporting Complete||13/02/2018|
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.