Shoal Bay Dementia
Profile & contact details
|Premises name||Shoal Bay Dementia|
|Address||33 Church Street Northcote Point Auckland 0627|
|Service types||Dementia care|
|Certification/licence name||Graceful Home Shoal Bay Limited - Shoal Bay Dementia|
|Current auditor||HealthShare Limited|
|End date of current certificate/licence||31 October 2021|
|Certification period||36 months|
|Provider name||Graceful Home Shoal Bay Limited|
|Street address||33 Church Street Northcote Point Auckland 0627|
|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: 30 August 2018
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||An annual training plan is not documented. Staff (including the registered nurse) have not all had training in dementia.||Document an annual training plan. Provide training to all staff on dementia.||PA Moderate||In Progress|
|There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery.||Not every shift has a staff member who has completed training in dementia||Ensure that each shift has staff member who has completed training in dementia.||PA Moderate||In Progress|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||The staff meetings do not evidence discussion of internal audit results. Resolution of issues is not documented at all times when issues are identified. Meetings have not been consistently held as per schedule since new ownership. Hazards are not documented to evidence that staff, residents (where able), family and visitors have been informed.||Provide feedback to staff around results of internal audits with discussion of strategies to address issues. Document evidence of resolution of issues. Review the schedule of meetings to ensure these meet staff needs and that they are held regularly. Document evidence of communication of any hazard.||PA Moderate||Reporting Complete||11/12/2018|
|The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.||The MoH and the District Health Board have not been formally informed of the change in management and clinical oversight.||Formally notify the Ministry of Health and the District Health Board of the change in management and clinical oversight.||PA Low||Reporting Complete||04/02/2019|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||The orientation programme does not include training around dementia or to key aspects of care for people with dementia.||Ensure that the orientation programme includes dementia or to key aspects of care for people with dementia.||PA Moderate||Reporting Complete||04/02/2019|
|Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer.||Not all files sampled had 24-hour activities plans in place.||Include 24-hour activities plans in residents’ files to guide staff in the management of behaviours of concern.||PA Moderate||Reporting Complete||04/02/2019|
|Advance directives that are made available to service providers are acted on where valid.||Three of seven resident files reviewed have an advance directive signed by the enduring power of attorney as well as by the general practitioner.||Ensure that only residents deemed competent are able to sign an advance directive or a general practitioner if a clinical decision is documented.||PA Low||Reporting Complete||08/04/2019|
|Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group.||The food service is not being provided in line with recognised nutritional guidelines.||Provide evidence that the menu was reviewed by the registered dietitian. Ensure the food service is registered under the new food control plan.||PA Low||Reporting Complete||08/04/2019|
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.
Audit reportsAudit date: 30 August 2018
Audit type:Certification Audit
Audit type:Provisional Audit