Montecillo Veterans Home and Hospital

Profile & contact details

Premises details
Premises nameMontecillo Veterans Home and Hospital
Address 63 Bay View Road South Dunedin Dunedin 9012
Total beds44
Service typesRest home care, Geriatric, Medical
Certification/licence details
Certification/licence nameMontecillo Veterans Home and Hospital Limited - Montecillo Veterans Home and Hospital
Current auditorHealth and Disability Auditing New Zealand Limited
End date of current certificate/licence06 July 2021
Certification period24 months
Provider details
Provider nameMontecillo Veterans Home and Hospital Limited
Street address 63 Bay View Road St Kilda Dunedin 9012
Post addressPO Box 7089 Mornington Dunedin 9040

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: 08 May 2019

Outcome requiredFound at auditAction requiredRisk ratingAction statusDate action reported complete
Service providers demonstrate their ability to provide the information that consumers need to have, to be actively involved in their recovery, care, treatment, and support as well as for decision-making.Two (both hospital) of four resuscitation orders where the GP had documented “Not clinically indicated” did not identify the decision had been discussed with family. Ensure where resuscitation orders state “Not clinically indicated”, there is also evidence of discussion with family. PA LowIn Progress
Where progress is different from expected, the service responds by initiating changes to the service delivery plan.Short-term care plans are not always evaluated and either resolved or added to the long-term care plans Ensure short-term care plans are evaluated on a regular basis and either resolved or transferred to the long-term care plan. PA LowIn Progress
The service is able to demonstrate that written consent is obtained where required.Three (hospital) of six consent forms had not been signed by the resident or EPOA to indicate they have or have not given consent. Ensure consent forms are signed by the resident or their enduring power of attorney. PA LowIn Progress
A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.In the last two years, there has been no education sessions on cultural safety, continence, food safety for all staff, or restraint. Ensure all staff receive all compulsory training sessions. PA ModerateIn Progress
Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.The controlled drug register does not always include the time of administration. Ensure the controlled drug register is fully completed. PA ModerateIn Progress
Each episode of restraint is evaluated in collaboration with the consumer and shall consider: (a) Future options to avoid the use of restraint; (b) Whether the consumer's service delivery plan (or crisis plan) was followed; (c) Any review or modification required to the consumer's service delivery plan (or crisis plan); (d) Whether the desired outcome was achieved; (e) Whether the restraint was the least restrictive option to achieve the desired outcome; (f) The duration of the restraint episode… (this text has been trimmed due to space limits).i) Three of three restraint long-term care plans, and one of one enabler long-term care plan have not been reviewed six monthly. ii) One of three restraint long-term care plans contained incorrect information. iii) Two long-term restraint care plans had no evidence of review or changes in interventions since 2013 and 2017 respectively. (i)-(iii) Ensure all interventions in the long-term care plans for restraint are individualised and reviewed at least six monthly. PA ModerateIn Progress
All records are legible and the name and designation of the service provider is identifiable.Not all designations were consistently identifiable by the registered nurses in the progress notes sighted. Ensure all progress notes written identify designations clearly. PA LowIn Progress
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.(i) One rest home resident did not have a long-term care plan documented within three weeks of admission. (ii) Three of three residents (one rest home, two hospital) who required interRAI six monthly reviews had not had their InterRAI assessments reviewed within required timeframes. (iii) Two of three (one rest home and one hospital) long-term care plans due for review have not been always been reviewed six monthly (iv) Three of three residents (two hospital, one rest home) who were due for a s… (this text has been trimmed due to space limits).Ensure that all aspects of assessments, care planning and care plan evaluations are completed within the required timeframes. PA ModerateIn Progress
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.One hospital resident did not have the pressure injury risk reassessed following the development of a stage 2 pressure injury. Ensure that residents are reassessed with a change in heath condition. PA LowIn Progress
The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk.i) Fifteen of fifteen incident forms reviewed do not identify opportunities to minimise risks of future incidents. ii) There was no incident report completed for a resident with a pressure injury. i) Ensure opportunities to minimise the risk are identified on the incident reports. ii) Ensure incident reports are documented for all pressure injuries. PA ModerateIn Progress
The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.The progress notes in one rest home and three hospital files reviewed did not evidence consistent review by a registered nurse including follow-up of reported pain and discomfort. Ensure progress notes evidence consistent review by registered staff. PA LowIn Progress
The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes.i) Two hospital level care residents on two hourly repositioning charts do not evidence this has occurred as planned. ii) The effectiveness of ‘as required’ analgesia has not been consistently recorded for two hospital level care residents. i) Ensure monitoring charts are completed as required. ii) Ensure effectiveness of ‘as required’ analgesia is documented. PA ModerateIn Progress
Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process.i) Three hospital residents had their care plan completed before the interRAI risk assessments had been completed. ii) A short-term care plan was not documented, or the long-term care plan updated to include interventions to support management of a new pressure injury. iii) One hospital resident (with a significant change in mobility), did not have the long-term care plan fully updated to identify the resident required the assistance of two care staff. iv) Two residents (one hospital and… (this text has been trimmed due to space limits).i) Ensure that the assessment process is used to provide information to inform the care plan. ii) -vii) Ensure that interventions are fully documented for all assessed care needs and changes in health status. PA ModerateIn Progress
Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.i) There is no evidence of any internal audits completed in 2018. ii) There is no planned audits schedule to include clinical, infection control and health and safety audits to be completed. iii) There is no evidence of completion of corrective actions. iv) Corrective actions have not been documented as discussed at staff meetings. Ensure an internal audit schedule is developed and implemented to include audits for all aspects of service delivery. Ensure all corrective actions identified are completed, signed off and discussed at meetings. PA ModerateIn Progress
The organisation has a clearly defined and documented infection control programme that is reviewed at least annually.The infection control programme has not been reviewed on an annual basis. Ensure the infection control programme is reviewed at least annually. PA LowIn Progress
A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines.(i) Medication temperatures were not consistently documented in the upstairs medication fridge. (ii) Four eyedrops in current use were past the documented expiry date and three eyedrops in current use did not evidence opening dates. i) Ensure the temperature of the medication fridge is checked and documented. ii) Ensure eyedrops are dated on opening and discarded as per manufacturer’s instructions. PA ModerateReporting Complete16/08/2019

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. 

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.

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