Premise details
- Address
- 60 Weka Street Miramar Wellington 6022
- Total beds
- 27
- Service types
- Psychogeriatric
Certification/licence details
- Certification/licence name
- Millvale House Miramar Limited - Millvale House Miramar
- Current auditor
- BSI Group New Zealand Ltd
- End date of current certificate/licence
- Certification period
- 36 months
Provider details
- Provider name
- Millvale House Miramar Limited
- Street address
- 34 Averil Street Richmond Christchurch 8013
- Postal address
Progress on issues from the last audit
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.
| Outcome required | Found at audit | Action required | Risk rating | Action status | Date action reported complete |
|---|---|---|---|---|---|
| Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services. | The service does not have sufficient numbers of registered nurses to always have a registered nurse on duty in the psychogeriatric wing to meet the ARHSS contract | Ensure a registered nurse is on duty 24/7 to meet the requirements of the ARHSS contract. | PA Low | Reporting Complete | |
| 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 | (i). One resident with acute issues (conjunctivitis) did not have an infection report or interventions documented. (ii). One resident did not have care plan interventions updated with a management plan as indicated by the district nurse. (iii). Five of five care plans did not include a 24-hour reflection of close to normal routine for the resident with detailed interventions to assist caregivers in strategies for distraction, de-escalation, and management of challenging resident behaviours. | (i). Ensure infection reports and care plan interventions are documented for acute issues as guided by the policy. (ii). Ensure care plans are updated to reflect specialist input to resident care. (iii). Ensure that all care plans reflect 24-hour management of the resident behaviours | PA Low | Reporting Complete | |
| Service providers shall ensure there are sufficient health care and support workers on duty at all times to provide culturally and clinically safe services. | Not all staff followed the systems and processes in place when rosters were changes. | Ensure all policies and procedures are followed when there are changes to the roster. | PA Moderate | Reporting Complete | |
| Service providers shall implement systems to determine and develop the competencies of health care and support workers to meet the needs of people equitably. | Staff have not completed all the required annual competencies as per the DCNZ education and training schedule. | Ensure that all staff have completed the required competencies to meet the needs of the residents. | PA Moderate | Reporting Complete | |
| Service providers shall ensure there is a system to identify, plan, facilitate, and record ongoing learning and development for health care and support workers so that they can provide high-quality safe services. | Mandatory training has been completed as scheduled since the last audit; however, there has been low numbers of staff attending or completing the required mandatory training in 2024. | Ensure all staff attend and complete the required mandatory training. | PA Low | Reporting Complete | |
| My complaint shall be addressed and resolved in accordance with the Code of Health and Disability Services Consumers’ Rights. | Timeframes for complaints resolution have not been followed to ensure ongoing communication and resolution within 20 working days for complaints reviewed. | Ensure that all complaints are managed in accordance with guidelines set by HDC. | PA Low | Reporting Complete | |
| Service providers shall understand and comply with statutory and regulatory obligations in relation to essential notification reporting. | Staff did not complete a section 31 notifications as per policy. | Ensure that the required notification under section 31 is completed as per policy. | PA Low | Reporting Complete | |
| Service providers shall engage with people receiving services to assess and develop their individual care or support plan in a timely manner. Whānau shall be involved when the person receiving services requests this. | Two resident files reviewed did not have initial assessments and care plans completed within the required timeframe. | Ensure that initial care plans and assessments are completed within the required timeframes | PA Low | Reporting Complete | |
| 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 | (i).Initial care plan for a recent admission did not provide detailed interventions to guide staff in the delivery of care in relation to a choking risk and behaviour management. (ii). One resident with aggressive behaviour did not have detailed interventions documented to guide staff in the delivery of care. The care plan for the same resident continued to mention that the resident was wandering yet they have been bed and chair bound since October 2024. | (i)-(ii).Ensure that care plan documentation reflects the residents’ current needs and that interventions documented provide detailed information to guide staff in the delivery of care for the residents. | PA Moderate | Reporting Complete | |
| 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 | (i).Three of three care plan evaluations have not been completed at the same time as the resident’s interRAI re-assessment, care plan review and MDT. (ii).Where progress was different from the expected goals as documented in the care plan evaluation, there was no evidence of updates to the care plan. | (i).Ensure care plan evaluations are completed at the same time as the resident’s interRAI re-assessment, care plan review and MDT. (ii).Ensure the care plan is updated, where progress is different from the expected outcome. | PA Low | Reporting Complete |
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 corrective action manager.
- Date action reported complete
The date that the corrective action manager was told the issue was fixed.
Audit reports
About audit reports
Audit reports for this rest home’s latest audits can be downloaded below.
Before you begin
Before you download the audit reports, please read our guide to rest home certification and audits. The guide gives an overview of the auditing process and explains what the audit reports mean.
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.
Before 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) appear on the rest home’s page. As the rest home completes the required actions, the status on the website updates.
Audit date:
Audit type: Surveillance Audit
Audit date:
Audit type: Certification Audit
Audit date:
Audit type: Surveillance Audit
Audit date:
Audit type: Certification Audit
