Shelly Beach Dementia

Profile & contact details

Premises details
Premises nameShelly Beach Dementia
Address 19 Shelly Beach Road Saint Marys Bay Auckland 1011
Total beds14
Service typesDementia care
Certification/licence details
Certification/licence nameGraceful Home No.2 Limited - Shelly Beach Dementia
Current auditorThe DAA Group Limited
End date of current certificate/licence02 March 2026
Certification period24 months
Provider details
Provider nameGraceful Home No.2 Limited
Street address30 Ranui Road Remuera Auckland 1050
Post addressPO 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: 04 December 2023

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Health care and support workers shall receive an orientation and induction programme that covers the essential components of the service provided.Not all staff have had an annual performance appraisal. Provide evidence that all staff have had an annual performance appraisal. PA ModerateReporting Complete25/06/2024
Governance bodies shall ensure service providers’ structure, purpose, values, scope, direction, performance, and goals are clearly identified, monitored, reviewed, and evaluated at defined intervals.There is no business/strategic plan for the facility available. Provide evidence that the governing body provides a business plan that identifies direction and performance, and goals are clearly identified, monitored, reviewed and evaluated at defined intervals. PA ModerateReporting Complete25/06/2024
Buildings, plant, and equipment shall be fit for purpose, and comply with legislation relevant to the health and disability service being provided. The environment is inclusive of peoples’ cultures and supports cultural practices.Maintenance to ensure the wooden decking in the front garden is non slippery and safe to walk on has not occurred. Ensure that the wooden decking in the front garden is non slippery and safe to walk on. PA ModerateReporting Complete25/06/2024
Service providers shall develop and implement a quality management framework using a risk-based approach to improve service delivery and care.Internal audits are not completed. Provide evidence that internal audits are being completed as per the 2024 audit schedule. PA ModerateReporting Complete25/06/2024
The governance body shall identify the IP and AMS programmes as integral to service providers’ strategic plans (or equivalent) to improve quality and ensure the safety of people receiving services and health care and support workers.:There is no evidence to identify that the IP and AMS programmes are integral to the service provider’s strategic and/or business plan. : Provide evidence that the governance body shall identify the IP and AMS programs as integral to the strategic/business plan. PA ModerateReporting Complete25/06/2024
Service providers shall understand and comply with statutory and regulatory obligations in relation to essential notification reporting.Not all essential reporting and notification events are being reported to comply with statutory and regulatory obligations. Ensure all essential reporting and notification events are being reported to the appropriate authority/agency in a timely manner to comply with statutory and regulatory obligations. PA ModerateReporting Complete25/06/2024
My service provider shall work in partnership with iwi and Māori organisations within and beyond the health sector to allow for better service integration, planning, and support for Māori.The facility has not developed a Māori plan in partnership with Māori communities. Provide evidence that shows the facility works in partnership with iwi and Māori organisations. PA LowReporting Complete25/06/2024
My service provider shall design a Pacific plan in partnership with Pacific communities underpinned by Pacific voices and Pacific models of care.The facility has not developed a Pacific plan in partnership with Pacific communities. Provide evidence of a partnership with Pacific communities to support residents that identify as Pasifika. PA LowReporting Complete25/06/2024
Service providers shall improve health equity through critical analysis of organisational practices.A critical analysis of organisational practices in regard to improving health equity has not occurred. Provide evidence that a critical analysis of organisational practices has occurred. PA LowReporting Complete25/06/2024
Service providers shall establish environments that encourage collecting and sharing of high-quality Māori health information.The facility is not collecting and sharing high-quality Māori health information. Provide evidence that shows collection and sharing of high-quality Māori health information. PA LowReporting Complete25/06/2024
Planned review of a person’s care or support plan shall: (a) Be undertaken at defined intervals in collaboration with the person and whānau, together with wider service providers; (b) Include the use of a range of outcome measurements; (c) Record the degree of achievement against the person’s agreed goals and aspiration as well as whānau goals and aspirations; (d) Identify changes to the person’s care or support plan, which are agreed collaboratively through the ongoing re-assessment and review … (this text has been trimmed due to space limits).Outcome scores from interRAI assessments were not consistently identified in long-term care plans. Ensure outcome scores from interRAI assessments are consistently documented in long-term care plans. PA LowReporting Complete25/06/2024
A medication management system shall be implemented appropriate to the scope of the service.Effectiveness of PRN outcomes were not consistently documented. Ensure the effectiveness of PRN medications is consistently documented. PA LowReporting Complete25/06/2024
An approved food control plan shall be available as required.The service does not have a current approved food control plan. Provide evidence of a food control plan. PA LowReporting Complete25/06/2024
Service providers shall have a clearly defined and documented IP programme that shall be: (a) Developed by those with IP expertise; (b) Approved by the governance body; (c) Linked to the quality improvement programme; and (d) Reviewed and reported on annually. The infection control programme has not been reviewed and reported annually as per policy and legislative requirements Ensure the infection control programme is reviewed and reported annually as per policy and legislative requirements. PA LowReporting Complete25/06/2024
Health care and support workers shall be trained in least restrictive practice, safe practice, the use of restraint, alternative cultural-specific interventions, and de-escalation techniques within a culture of continuous learning.Staff training in restraint and de-escalation techniques has not occurred. Provide evidence that staff have been trained in restraint and de-escalation techniques. PA LowReporting Complete25/06/2024

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.

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