Focused inspection of Hillview Care Services downgraded the service from Good to Requires Improvement, with a breach of Regulation 17 (Good Governance) due to incomplete records, MAR transcription gaps and ineffective quality assurance. Feedback from people and relatives was positive about safe, punctual and kind care, and the registered manager was open and committed to improvement.
Concerns (7)
criticalGovernance: “Effective governance systems were not always used to monitor the service. Accurate and complete records of people's care had not always been maintained.”
criticalRecord keeping: “Records relating to people's care and the management of the service were not always kept or sufficiently comprehensive.”
moderate
Medication management
: “we found a small sample of MARS that did not include the dosage and frequency of medicines as per prescription.”
moderateCare planning: “the control measures of some people's preferences in the management of their dietary risks were not always clear.”
moderateStaff competency: “the provider's quality monitoring systems of staff development had not identified that staff had not received an annual review of their medicines competencies in line with guidance.”
moderateInfection control: “the provider was unable to demonstrate through their records how they were monitoring and meeting the COVID-19 testing requirements of care staff.”
minorSafeguarding: “The provider had not ensured that their safeguarding policy reflected the local authority in which care was being delivered.”
Strengths
· Relatives reported staff were kind, punctual and communicated when running late
· Small, regular staff team familiar with people's needs and medicines
· Safer recruitment procedures were followed
· Staff trained in safeguarding and knew how to report concerns
· Additional specialist training provided (e.g. PEG training)
Quality-Statement breakdown (10)
safe: Staffing and recruitmentNot rated
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongNot rated
safe: Using medicines safelyNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Preventing and controlling infectionNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: Continuous learning and improving care; duty of candourNot rated
well-led: Engaging and involving people using the service, the public and staffNot rated
well-led: Working in partnership with othersNot rated