Shoal Bay Dementia
Profile & contact details
Premises name | Shoal Bay Dementia |
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Address | 33 Church Street Northcote Point Auckland 0627 |
Total beds | 26 |
Service types | Dementia care |
Certification/licence name | Graceful Home Shoal Bay Limited - Shoal Bay Dementia |
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Current auditor | The DAA Group Limited |
End date of current certificate/licence | 31 October 2024 |
Certification period | 36 months |
Provider name | Graceful Home Shoal Bay Limited |
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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: 17 April 2023
Outcome required | Found at audit | Action required | Risk rating | Action status | Date action reported complete |
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A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers. | Two staff have not completed an industry approved qualification in dementia care within 18 months of employment. One staff member employed for 17 months has yet to be enrolled. | Ensure all care staff complete an industry approved qualification in dementia care within 18 months of employment. | PA Moderate | Reporting Complete | 15/02/2022 |
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers. | The minutes of management meetings held since February 2021 could not be located. The results of internal audits, satisfaction surveys and changes in policy are not explicitly noted as being discussed in the meeting minutes sighted. | Ensure records are maintained of the discussions included in the management meetings. Ensure the results of internal audits, satisfaction survey and amendments to existing policy are discussed at applicable meetings and appropriate records maintained. | PA Low | Reporting Complete | 04/07/2022 |
An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken. | The complaints in the complaints register are incorrectly noted as being closed on the date the complaint was received and before all required interventions have been completed and monitored for effectiveness. The complaints register does not include details of all actions taken. | Ensure complaints are only closed after appropriate actions have been taken to address the complaint. Ensure the complaints register includes details of actions taken in response to every complaint. | PA Low | Reporting Complete | 04/07/2022 |
Service providers shall implement systems to determine and develop the competencies of health care and support workers to meet the needs of people equitably. | Care staff have not yet completed cultural competencies or education on equity. | Ensure the service implements systems to determine and develop the competencies of health care assistants to meet the needs of people equitably. | PA Low | Reporting Complete | 21/12/2023 |
Fundamental to the development of a care or support plan shall be that: (a) Informed choice is an underpinning principle; (b) A suitably qualified, skilled, and experienced health care or support worker undertakes the development of the care or support plan; (c) Comprehensive assessment includes consideration of people’s lived experience; (d) Cultural needs, values, and beliefs are considered; (e) Cultural assessments are completed by culturally competent workers and are accessible in all settin… (this text has been trimmed due to space limits). | Two out of five residents’ files sampled did not have an initial care plan completed. Three out of five residents’ files sampled for review did not have initial interRAI assessments and long-term care plans completed. The interRAI assessment summary report evidenced that 19 routine six-monthly interRAI reassessments were overdue with an interval of between 86 and 207 days. One file was overdue for six-monthly care plan evaluation. | Ensure interRAI assessments and long-term care plans are completed and evaluated in the timeframes required by the aged related residential care contract. | PA Moderate | Reporting Complete | 28/02/2024 |
A medication management system shall be implemented appropriate to the scope of the service. | Four opened eyedrops in use were past use by dates. | Ensure all eyedrops in use are within the current ‘use by’ dates. | PA Moderate | Reporting Complete | 28/02/2024 |
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.
Audit reports
Audit date: 17 April 2023Audit type:Surveillance Audit
Audit date: 17 August 2021Audit type:Certification Audit
Audit date: 30 August 2018Audit type:Certification Audit
Audit date: 24 August 2017Audit type:Provisional Audit